Laserfiche WebLink
County <br /> �rrrr�,.• ty r <br /> Safety and Buildings Division t <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Peradf Nt l ber.(to be filled in by Co.) <br /> Madison, WI 53707-7162 5 •770 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,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 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),Stars, iC �fJ/,e�.,y� f <br /> 1. Application Information-Please Print All Information P/f <br /> Property Owner's Nam Are e Parcel# <br /> 4� LAAI�0vt'5t <br /> Property Owner's Mailing Address� �t/ C,�1r Property Location� ✓� 01_ G' V' CI / f// 5 t 44 Govt.Lot <br /> lt` <br /> City State ZipCode Ph eNumber <br /> f /�� ry// /• f C '/a, 44, Section <br /> M t/V/V t' [ f 51 m ! ' / C I �Q/ ( � `. �c2 (circle one) <br /> II.Type of B llding(check all that apply) Lot# T N; R E or W <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> _ - Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> la Townof�( � al <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System El Replacement System Treatment/Holding Tank Replacement Only El 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 System/Component/Device: 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 /> IHolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) _ <br /> V.DispersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks ) <br /> 0 <br /> G. U in y v) Gc U 0. <br /> Septic or Holding Tank ^^WO 3000 <br /> —L+ L Ise <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 /> CIA e/t/ /A A15/Ir d 213 15- 10 j/tom <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a 7b th q 16461 5� <br /> II.County/Department Use Only <br /> Approved Disapproved <br /> Permit Fee Date Issued Issuing Agent Sign me <br /> ❑ <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approv"easons for Disapproval <br /> p ECEIVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than a ttz x I t incl it a AUG n 2'2 0 1 c <br /> SBD-6398(R. 11/11) BURNETT COUNTY <br /> ZONING <br />