Laserfiche WebLink
e„r,,, Countypi <br /> Industry Services Division GQ f'II e <br /> -• '• 6 1400 E Washington Ave <br /> ``$P$ P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,, Madison,WI 53707-7162 S- --421 —/o� <br /> G 3c/D`i <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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing add <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 5 PVC 1// 0 7 �J <br /> L Application Information-Please Print All Information > <br /> Property Owner's NameParcel 4 $f�DD ( 01 soo(? <br /> A )�XSGnaate 'Vedic!' 07ogz-z; F2scosoo7 . <br /> Property f Owner's Mailing Address Property Location <br /> I Z V3 3 V/? A Ve jV _ Govt.Lot 7 <br /> City,AState --^^ ^/ ZipZi` Code Phone Number <br /> � �/ J ln/'/< L4%, Section ZS— <br /> l r' 1�e0( l>I !Y I /► J C(� 612-50 1 3 � / � �� 1 d ciE a one) <br /> T N R Eoe <br /> II.Type of Building(check all that apply) -7Lot 4 <br /> 11] 1 or 2 Family Dwelling-Number of Bedrooms_ 1-1 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block 4 <br /> of <br /> 0 State Owned-Describe Use El City ge <br /> fCSMINyVumbeer ❑ Villaof <br /> Wig I.c i' iv Town of Woo n , <br /> ier Ai Weis <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. M New System ❑ Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal 0 Permit Revision 0 Change of 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow Design Soil Application Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> ti Rate(gpdsf) ----------- <br /> VI.Tank Info Capacity in <br /> C.) c <br /> Gallons Total 4 of . -- U N <br /> Manufacturer a o <br /> Gallons Units °-� c :: v <br /> New Tanks Existing Tanks a`, U , , iz, C7 a. <br /> Septic or Holding Tank 7,00 V .-.--. ?Z`y'}f�` 1 W / <br /> F�e t - o o ❑ o <br /> Dosing Chamber at <br /> !� 0 0 0 0 0 <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 Signa2., MP/MPRs Number Business Phone Number <br /> Pat Kissack / 881072 715-520-2335 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W7003 Rappy Lake Rd.,Trego WI 54888 <br /> VIII.County/Department Use Only <br /> lir-Approved 0 Disapproved Permit Fee Date <br /> Issued Issuin /ent Sigatu <br /> 0 Owner Given Reason for Denial $ 3 7Sr tl'/�'d, /''re <br /> IX.Conditions of Approval/Reasons for Disapproval , E (f�`� EW <br /> OCT ED <br /> 3 0 2020_ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 1 11 inc in size $37�) <br /> Burnett County <br /> SBD-6398(R03/14) Land Services Department <br />