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County <br /> Industry Services Division R"rvl e_ff <br /> fir+. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> PS `� P.O. Box 7162 SS8r10� <br /> y ' Madison,WI 53707-7162 <br /> XP s�nl—ib—) <br /> Sanitary Permit Application Slate Transaction Number <br /> In accordance with SPS 393.21(2),Wis.Adm.Code,submission of this form to the appropriate govenunental unit <br /> is required prior to obtaining a sanitary pennit. 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 SrsI <br /> purposes in accordance with the PrivacyLaw,s.15.04(1)(m),Stats. /Pa" f- <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> d✓!at- k ��ulse o^7- odty-a-Yo-go-/9 <br /> 3dO--0y H000 <br /> Property Owner's Mailing Address Property Location <br /> rt <br /> v o6 4V e- Govt.Lot <br /> City,State? Zip Code Phone Number y, '% Section J� <br /> .�j- f A to I M/V SSS/Q Z/ �pSl- -7S--5-- J b 6o 6F (circle one) <br /> T y0 N; R <br /> IL Type of Building(check all that apply) u Lot# _Z(� Eore✓ <br /> 13 1 or 2 Family Dwelling-Number of Bedrooms ! 3 Subdivision Name\)&n5orl5 <br /> Block k pi <br /> ❑Public/Commercial—Describe Use /D ❑ City of <br /> El State Owned—Describe Use CSM Number ❑ Village of <br /> ® Town of Oe. /6H [� <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 19 New System p ❑Treatment)Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> y ❑ Replacement System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Pennit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> WNon-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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> (ev r S / A00 /JOO 9s3 qSG s8 <br /> VI.Tank Info Capacity in Total k of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks <br /> Existing Tanks <br /> c J m y 4 U d <br /> Septic or Holding Tank <br /> Dosing Chamber 7j r7 Iso <br /> VII.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 /> ,e-re W&Ld let� izs >� J sus/ ��s-BGG-vis- 7 <br /> Plumber's Address rStreet,City,State,Zip Code) <br /> t S Gt/-e bs f r� j�t8'9' <br /> VIII.Count /De artm t Use Only <br /> Permit Fee O Date Issued Issuing Agent Signatur <br /> Approved El Disapprovede <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> nn ECEIV�E <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IR x 11 Inch <br /> JUL 0 8 1016 <br /> SBD-6393(90313) BURNETT COUNTY <br /> ZONING <br />