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r County <br /> Q Safety and Buildings Division <br /> ] 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State �nNumberu , _ <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Y�9�(e_w-t CMS <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 <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Slats. <br /> I. ApplicationLformation—PleasePrintAllInformation �/NR54�e 5� cJ <br /> Property Owner's Name a Parcel# O-7 O/a -2 �VO <br /> Z- o 0 6 o cb <br /> Property Owner's Mailing Address Property Location <br /> o-3 <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> t %a, '/., Section <br /> g"/ /� rIj k� r -7 circle one <br /> II.Type of Building(check all that apply) Lot# T N; Rte_E <br /> i <br /> �tor2 Family Dwelling-Number of Bedrooms 3 .� Subdivision Name <br /> �. Block# r& re �.f. �a <br /> ElPublic/Commercial-Describe Use <br /> ❑City of �- <br /> ❑State Owned-Describe Use �— CSM Number ❑village of ,rte <br /> -Mown of c_e—-5 D 1� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System XReplacemen[System ❑Trea[ment/Holding 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 onenUDevice: Check all that apply) <br /> )3-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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ys6 6 C/3 Ei/SO o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks w 'o <br /> � U ti ti wC7 0.. <br /> Septic or Holding Tank d �7�O 3 OO G M CSG <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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ,�&`A4-- X"i <br /> Plumber's Address(Street,City,State,Zip Code) <br /> e <br /> O x Jd <br /> fic) 7 7 <br /> VII .Court Ne artment Use Onl <br /> Approved ❑Disapproved Permit Fee Date Issued �"� Issuing t Si ure <br /> ❑ Owner Given Reason for Denial $ ' w 30 �L L(,I Z U <br /> CE n <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APR 3 0 2012 <br /> BURNM COUNTY <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x Il inches in size ZONING <br /> SBD-6398(R. 11/I1) <br />