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"\ <br />Industry Services Division <br />County <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />�._ ICS <br />Sanitary Permit Application <br />State Transaction Number <br />,v A , <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />ses in accordance with the Privacy Law, s. 15. 1 m Stats. <br />I. Application Information <br />- Please Print All Information <br />Pro erty O er's Name <br />parcel # <br />< <br />o` <br />�t( / <br />-F-2.4o- <br />Property Owner's Mailing A s <br />Property Location <br />/ <br />�M <br />Gc1vt. I of 41' <br />ALI. j�,y/ �/� �� V1 motion <br />2.0 <br />City, State Zip Code <br />Phone Number <br />circle on <br />T_N; R_t+ E <br />IL Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />1 or 2 Family Dwelling - Number of Bedrooms 3 <br />L <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />V 1 <br />TO. of <br />III. Type of Permit: (Check only one bog on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />Replacement System <br />❑ Treatment/llolding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />Change <br />❑ Chane of Plumber <br />Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type <br />of POWTS S stem/Com onent(Device: Check all that apply) <br />❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />ig Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersaVrreatment Area Information: <br />I70 <br />DFl 7d) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />-1 <br />Gallons <br />Gallons <br />Units <br />O <br />U <br />New Tanks Existing Tanks <br />TO <br />L1r U <br />m � k, C7 <br />f1. <br />Septic or Holding Tank <br />G <br />Dosing Chamber <br />VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name Print) Plumbe ' Si Lature MP/MPRS�N)umber Busin)esscPhone Number <br />' <br />v �/ J <br />Plumber's Address (Street, City, State, Zip Code) <br />w 7 d 3 ka gczy Len k <br />VIII. Coun !De artment s ni <br />AApproved <br />❑ Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Signature <br />11Owner Given Reason for Denial <br />'3 DD <br />375"' <br />a <br />IX. Conditions of Approval/Reasons for Disapproval <br />APPROVED <br />Attach to a .W. M.— q A....,.b... e..a .«ti.-.:,. ._ ..._ <br />SBD -6398 (R. 08/14) <br />Ira <br />OCT <br />�._uv <br />ZGi8 <br />LJ <br />BURNETT COUNTY <br />7r1nn nlr_ <br />