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'Ynare.�}ems. - County <br /> �,. + ` Industry Services Division 0l40^/1 of <br /> ,- Dt s.,. > 1400 E Washington Ave Sanita Permit Number(to be tilled in by Co.) <br /> P 0 Box 7162 �aa�i 7 <br /> 1y } �S Madison,WI 53707-7162 <br /> t S -71 <br /> Sanitary Permit Application Sate Transaction Number <br /> In accordance with SPS 383.21(2),Wis,Adm.Code,submission of this form to the appropriate govermuental 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 Servies. Personal information you provide may be used for secondary of 7 70 7 <br /> purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats.L Application Information—Please Print All Information �t/r"' e✓ /�d. <br /> Property Owner's Name Parcel# <br /> Grt JP. Srrr�fL t+7` sdm-�^rfa-16�.t7-s <br /> Yys- o//(eeo <br /> Property Owner's Mailing Address ^^ Property Location <br /> 7,S O j H 4fA,0(ew Gras S C.��D✓e <br /> Govt.Lot <br /> City,State Zip Code Phone Number y,, ''%, Section Z 7 <br /> (circle one)6114 w VVdvG Mq/ SS"O/6 T�N; R16Eorptr <br /> II.Type of Building(check all that apply) Lot# <br /> I1 I or 2 Family Dwelling—Number of Bedrooms 91 �n (� Subdivision Name Block# V ��M1 <br /> 1 d <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSNT Number ❑ Village of <br /> Q Town of �'}QlL 14 aQ( <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System Replacement System ❑TreatmenttHolding 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 <br /> IV.Type of POWTS S stem/Com ponent/Device: (Check all that apply) <br /> Non-Pressurzed 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks '2 o v m ra <br /> Septic or Holding Tank 7.�0 7S"O 1 W/�$ti✓ x <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) <br /> Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rec/G 114,0/4rn 5 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1774 A. V ,7.s- we bs�.� r,✓y �y 3 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Si rare <br /> Approved El Disapproved❑ Owner Civen Reason for Denial $ 3')S. OO Ill- 1 DQ <br /> f 1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECE0VE <br /> iIL 17 <br /> Attach to complete plans for the system and submit to the County only on paper not less than g tC s 1t inc in si <br /> it 0 <br /> BURNETT COUNTY <br /> ZONING <br /> SBD-6393(R0313) <br />