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; anurt ,,}3.R County <br /> Industry Services Division i3t,.rrt t 74 <br /> fit) Q' r 1400 F_Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> # S P N P.O. Box 7162 [� <br /> Madison, WI 53707-7162 _,!�>q <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 fors 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(I)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# 011_ <br /> L �S6 /�Bwer s oa8-a _ <br /> Property Owner's Mailing Address Property Location <br /> yjJ 7S rr a.i N;e <br /> /?:6,p Govt Lot <br /> City,State Zip Code Phone Number i i <br /> /., Section <br /> L a A ii /h N (circle oneln <br /> I1.T pe of Building(check all that apply) Lot N T�D N; R E o 4 <br /> I o[2 Family Dwelling—Number of Bedrooms _—_ 3 ty CL.� Subdivision Name J 1) <br /> Block# �Upl /woo <br /> ❑Pubtic/Commemial—Describe Use / <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Town of .J CoT`f <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System PrTreatmendHoldm2 <br /> y ❑ Replacement System a 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 )(v�nt/I —� <br /> IV.Type of POWTS Sys tem/Com onent/Device: (Check all that apply) <br /> ,� Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ AI-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(st) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o 'E <br /> New Tanks Existing Tanks ;= u SR Z y <br /> o t° <br /> c`.U � m ✓� ii. V 6. <br /> Septic or Holding Tank Aer0 <br /> Dosing Chamber s-s/O S`y <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 <br /> Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7G4 //—t. �iS web ffr. �/1 �S'S1`3 <br /> VIII.Count /De artmeor Use Only <br /> Approved Disapproved <br /> Permit Fee D Date Issued Issuing Agent Signa 'e <br /> ❑ $ ,5- 0 /0 P — <br /> i <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Em <br /> CEI <br /> Attach to complete plans rnr the system and submit to the County only on paper not less than A u>s 1 me es in size <br /> OCT 0 6 2016 <br /> SBD-6393(R0313) BURNETT COUNTY <br /> ZONINr, <br />