Laserfiche WebLink
County <br /> Industry Services Divisions.r n a <br /> ash; 1400 E Washington Ave <br /> ,� " lYl 9 Sanitary P t/Numb er�(/�o be tilled in by Co.) <br /> PS P.O. Box 7162 ���1!i✓ ! <br /> �•.` Vyj Madison,WI 53707-7162 <br /> `:TY; y <br /> Sanitary Permit Application State TransactionNunber <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(i different tan mailing address) <br /> the Deparnnent of Safety and Professional Servies. Personal information you provide may he used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information J <br /> Property Owner's Name G' CIA-d-'�o-t5'-Ll.)+S'/S los- yooe <br /> r We t�ti"r-EGC 'a3d"mi0 <br /> � 036 eeo <br /> Property Owner's Mailing Address Property Location <br /> 3 e in k Govt Lot <br /> City,State Zip Code Phone Number <br /> '/, Section <br /> N. Si btnf' f�Jlt/ SS/00 Lircleone) <br /> II.Type of Building(check all that apply) Lot N <br /> T y0 N; R 45 P,orO <br /> 19 1 or 2 Family Dwelling-Number of Bedrooms Aof L/ �S a 6 Subdivision Name <br /> Block# Jk I(� I . , <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of_ <br /> E Town of LJdL 6 k'S O h <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. C!New System y. 11 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 /> ❑ I-folding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Annhoation Rate(gpdso Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 3 v d , 11 7Y-0 1 y,-o <br /> VL Tank Info Capacity in -Total #of Manufacturer <br /> Gallons Gallons Units Z o '� o <br /> New Tanks Existing Tanks q `-' V v <br /> Septic or Holding Tank 7s-0 <br /> Dosing Chamber ery v -eW <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 /> / 7/S- �lv6-41la-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 4b7760 />11.. 3� lNebs�4r �tSS3 <br /> V1I1.County/Department Use Only <br /> Approved ❑ Disapproved PermittFFee Date Issued / Issuing Agent SignaNr <br /> ElOwner Given Reason for Denial $ 3 75' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEIVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 12 ill i hes size APR 18 2016 <br /> UU <br /> SBD-6398(80313) BURNETT COUNTY <br /> ZONING <br />