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County <br /> Safely and Buildings Division &1I'N er <br /> 1400 E Washington Ave Sanitary Permit Number(to be Jilted in by Co.) <br /> P P.O. Box 7162 rJrJ.331 <br /> Madison,WI 53707-7162 <br /> s -ly ! <br /> Sanitary Permit Application State I ransection Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Coda,submission of this form to the appropriutc covermacmal unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-,woad PO W'1'S am subminad to Project Addroo ofditffirenl than mailingaddress) <br /> the Dcparintenla[Safcty and Profeviolaed Services. Personal information you provide may be used for secondary _7 7 R I <br /> u a in eecaNabeewiththe Pdvm Law,s. 15.041 m Slate. a Tj(JN G11 <br /> L Application In formation-Please Print All Information G O/ <br /> Property Owner's Name Parcel <br /> cher V/ LA-m6 s 05-00/ _6z up/ <br /> Property Owner's Mailing Address Property Location <br /> Govt Lot <br /> Ciry, tete lip Code Phone Number 9,, A, Section <br /> katoone) <br /> II.Type of BuildJ `�ing(check all that apply) (/ Lot 0 T .39 N; R e ore) <br /> Lor 2 Family Dwelling-Number of Bedrooms 3 - 7 Subdivision Name <br /> Block M <br /> ❑Public/Commercial-Describe Use 11I <br /> City of <br /> C1 State Owned-Describe Use CSM Number 11 Village of <br /> V Z P Z 3 PeJown of Z <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ❑ New System 3-ItrpIdeantcirt System D 1 matracntlNolding Tank Implaccmout Only DOdmr Modification to Existing Systcm(explain <br /> Is. ❑ Pcrmi[Rcncwal ❑ Pcrtnit Revision D Change ofl'lumher O Permit Trunsfcr t,New List Previous Permit and Date Issued <br /> Before Expirvtian Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> U NonBress rrizcd In-Ground 0 Pressunced In-Ground U At-Grade U Mound>24 in.ofsuitable soil U Mound 124 in.ofsuilablesoll <br /> Holding Tank U Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area In formation: <br /> Design Flow(gpd) Design Soil Application Ra[c(gpdsQ Dispersal Arca Required(5-0 Dispersal Arco Proposed(s0 System Elevation <br /> /,00 — — I — I — <br /> VI.Tank Info it ll I Capadly in v Total Nof Manufacturer <br /> Gallons Gallons Units v <br /> Ncw Tvlka Gxisliag'Cank. 3 tl $ <br /> y�NoldingTmik 3,36) -- 3oa a GrvfL <br /> Dosing Chamber <br /> M <br /> onsibility Statement- 1,the andersh ord,assume responsibility for handintiun.1 he POW PS shown an the atmrhed plans. <br /> Plumber's (Print) Plumber's Signamrc MP/MPRS Number Business Phone Number <br /> FSHOLM A 1 x/ .g� 227691 715-349-7286 <br /> Address(Street,City,State,Zip Code) W n•��� <br /> t4,SIREN,WI 54872 <br /> ntdDc artment Use Onl <br /> Permit Fac Data Issued Issuing Agent Signator <br /> ed ,Disapproved <br /> D Owner Given Reason for Denius � t <br /> . itions ofApproveVReesdns for Disapproval n C" c�r� V r�L <br /> /�1u57 �aU5aLff7J (�Uf6D2 uG 5-E Ea DER ZS5K 382. 3o(a). �� <br /> um GST tiEu seR�oi a GovrY2mT�yr <br /> VBG 5�e�D P7t<e^ i P- ue J nwa u r7F(� SEP 2 9 2014 <br /> Amid,to corm ale P nnn for Ire system and rubmil m the County only on puwr not Ins pre. a m z 11 mnres,n <br /> zx <br /> BURNET7 COUNTY <br /> — ZONING <br />