Laserfiche WebLink
{r•sarifr yr, County <br /> Industry Services Division Burnett <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> ij <br /> �� <br /> �, q �=; Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Cock,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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than trailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 27947 Lone Pine Rd <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Denise Ritchie 07-020-240-16-29-5 05-001-023000 <br /> Property Owner's Mailing Address Property Location <br /> 408 West Chruch Street <br /> Govt.Lot 1 <br /> City,State Zip Code Phone Number Y<, '/,, Section 29 <br /> Ellsworth,WI 54011 612-986-1989 Icircle one) <br /> T40N R16Eo W <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City Of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> Vol.5 Pg.63 ® Town of Oakland <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System ® Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S stem/Com onentiDevice: (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 Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> O s o `ate(gp&`' W n- NP, N A ,v 6 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of <br /> Manufacturer <br /> Gallons Units u o ;; 8 ,n <br /> New Tanks Existing Tanks 2Q. U C7 <br /> Septic or Holding Tank 2000 2000 l Wieser ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) m �'• urc _ MP/MPRS Number Business Phone Number <br /> Daniels Plumbing&Heating Inc 007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 24056 State Rd 35/P.O.Box 326,Siren,WI 54872 <br /> VIII.Count /De artment Use Only <br /> kp <br /> proved ❑ Disapproved Pennit Fee_ 06 Date Issued Issuing Agent Signatur <br /> ❑ Owner Given Reason for Denial $ 3:7 Q' �' �� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �Zo/ /[atV S/oAvs �,trk 2407 y /A ���oyc eoddt;RV Aero . <br /> ICEENE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IRxllisi <br /> SBD-6398(R03/14) BURNETT COUNTY <br /> ZONING <br />