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County <br /> � F Industry Services Division <br /> QS. ' 1400 E Washington Ave Sanitary Pcrmit Number(to he tilled in by Co.)P1 P.O. Box 7162 <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 govetnntental unit <br /> is required prior to obtaining a sanitary permit. Note:Application tones for state-owned POINTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary qq ,D <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. p Lt 9 3 g .Spp <br /> I. Application Information-Please Print All Information / S <br /> Property Owner's Name Parcel# <br /> 07-OIfo-d-39-r`I J y'iOA moo <br /> JQ v''C 01 y J A h 3 o on 01 AC916 <br /> Property Owner's Mailing Address Property Location <br /> ) tic/3 8 Govt.Lot <br /> City,State Zip Code Phone Number _NW-_1/ _!Sj�y, Section YJ <br /> GSy (circle one <br /> 39 <br /> Il.Type of Building(check all that apply) Lot# T N; R /cl Eo{ p <br /> .1Ior2Family Dwelfin--Nut berofBedrooms -� I Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> m Town of �/• ✓��"3 h/a n�• <br /> P, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System y ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only 91 Other Modification to Existing System(explain) <br /> e XJani to -? YR <br /> B. ❑ Permit Renewal ❑ Permit Revision <br /> ❑ Change of Plumber ❑Permit Transfer toNew List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/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 /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpelst) Dispersal Area Required(s0 Dispersal Area Proposed(st) System Elevation <br /> 4t5­0 6 ti3 (. .f/ �,�,e <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units D o v u <br /> J y <br /> New Tanks Existing Tanks 2 <br /> Septic or Holding Tank 3 Z d 7 J!-'� <br /> /070 � W,� 3r ✓ <br /> Dosing Chamber <br /> VR.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 /> /G a Al lee /7� /Y oldsa's/ 7/jr--go 1_57 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J77(oj /� 3S— �.9e5oS�Yr LCL S g`73 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Date Issued Issuing A t ign re <br /> ❑ Owner Given Reason for Denial S O� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEI <br /> Attach to complete plans for the system and submit to the County only on paper not less than R 1/2 z 11 +heJJ size <br /> NOV 16 2015 <br /> SBD-6398(R0313) <br /> BURNETT COUNTY <br /> 7nkiwe-% <br />