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�Er{Rr„E,,rA Department of Safety c°°° �,�, <br /> & Professional Services, Sanitary Permit umbTerr(to be filled in by Co.) <br /> *x � Industry Services Division �1 It <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 state-owned 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.15.04(l)(m),Slats. <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel <br /> D�SO -2-4 I-1 to•35-5- I5-Z351- <br /> Property Owner's Mailing Address Property Location <br /> �'^ 'TO X- lb 22(O3� <br /> 5 1- 1,o -)6, Q Govt.Lot <br /> City,State Zip Code Phone Number <br /> e l,v Sy 3 L) 115-3.7 I-2�r� / ''/., Section <br /> II.Type of Buil ing(check all that apply) Lot# T L_N R_J_V E o <br /> *or 2 Family Dwelling-Number ofBcdrooms 2 t5 Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# -SA� S RIUtcV <br /> iEyj Emu <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> ,$Town of 5 W <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A' ❑New System ❑Replacement System Other Modification to Existing System(explain) El Additional Pretreatment Unit(explain) <br /> P,36�e)6 }ern k 4 f G� rW <br /> B' ❑Holding Tank ❑ In-Ground ❑ At-Grade ❑Mound ❑ Individual Site Design ❑Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑Revision ❑ Change of Plumber ❑Transfer to New Owner tst Previous Permit Number and Date Issued <br /> Expiration '2► -I LD <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> yZ.� y3 I 43-5 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units U d H y <br /> New Tanks Existing Tanks c a <br /> `_ a` U fn m w C7 0 <br /> Septic or Holding Tank 510 '0 1oO i S bD 7 _r, � A 0,,`oC X <br /> Dosing Chamber t W <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> R; Lk 1�0 ;A 5 s r CL 16(,9 - / <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 277(0o (-Et„y IS eh 54,erw <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ `�I�l�25 <br /> Conditions of Approval/Reasons for Disapproval a /] <br /> MAY 15 2025 <br /> 0' <br /> L <br /> 7 � ,`ri� a4orni or u�, ff__(, At- -l-in -tv ty_i S�'i n iu R Burnett County <br /> Attach to complete plan for the system and submit to the County only on paper not less than 8 1/2 11 <br /> SBD-6398(R.03/22) <br />