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Industry Services Division County <br /> s 1400 E Washington Ave r n N <br /> s P.O.Box 7162 <br /> 4-1 ' � Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note:Application forms for stat"wced POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15. 1 m,Stars. <br /> L Application Information—Please Print All Information <br /> Property�/t wn jOOer's Name Parcel# Qff-t <br /> o <br /> Al c G c� C, �Q X t� 20 1 1 <br /> Property Owner's Mailidg <br /> [Address / Property Location <br /> �� 7 0���r2 J►�.y� Govt.Lot�/9^t f !-.:�r•7��1�J <br /> C, State Zip Code <br /> `� Phone Number y., /4, Section <br /> IS��XI'1 CJi G-e� rr Ile -.47 �F T -��+ (circle one) <br /> H.Type of Buildin check all that apply) Lot# p O N; R E or <br /> (�1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑PublicJCommercial-Describe Use <br /> ❑City of <br /> CSM Number El Village of <br /> ❑State Owned-Describe Use �^7 <br /> 1 I Z9 ®Town of CA-X--e) <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New Syste n Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner �;3 Z j <br /> IV.Type of POV;TS S m/Cu HDeviee: Check all that <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(exgxlain) <br /> V.DispersaltTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Catty in Total #of Manufacturer <br /> i <br /> Gallons Gallons Units ;? U O„ <br /> New Tanks Existing Tanks c 2 E r2 5 <br /> a U in 55 ,n U. Q A. <br /> Septic or Holding Tank <br /> Dosing Chamber 7� <br /> VQ.Responsibility Statement-I,the andasgmed,assume responsibility for installation of the POWTS shown OR the attacked plans. <br /> Plumber's Name(Pri Phml ,s SlEg MP/MPR.S Number BtrsQeess Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> to S f rc4e-P <br /> VIIL Court /Department Use Only <br /> ved ❑Di ved Permit Few Issued <br /> A Issuing t Signature� <br /> ❑Owner Given Reason for Denial 2412D <br /> DL Conditions of Approval/Reasons for Disapproval <br /> au se- S <br /> COIlow W Ca c 4q h'�{/W S uk rt yu;rt e m i <br /> Attach to eampkae plans for the systtat Rod saint to the Canty edy an paper mot lea than 3 In x 11 sia <br /> MAY 21 2024 <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br /> $315 cukc k * I o519 <br />