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County <br /> Safety and Buildings Division V <br /> „ f t , '. 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> as�.$RS ,"�� Madison,WI 53707-7162 <br /> Stale Transact nNumber <br /> Sanitary Permit Application /�°/' y� � <br /> In accordance with SPS 383.21(2),W is.Adm.Cale,submission of this form to the appropriate governmental unit (/SMT J 7` vxr.J <br /> is required prior to obtaining a sanitary permiL Note:Application forma for sWa+owned POWYS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Setvies. Personal information you provide may be used for secondary - <br /> purposes in accordance with the Privacy Law,s. 15.04(l Xmh Stats. GG <br /> 1. Application Information-Please Print All Information 9356 f$,iQ/,;//A f hGS O,lK <br /> Property Omer's Name Parcel g t71 O/2-Z'¢O'(S'0/:S�'GtY('O <br /> T , eTeirje- b s- O Zytolp yal7 <br /> Propeary Owner's Mail( Address O Property Location <br /> Govt.Lot At <br /> Ci .State ( Zip CodePhonePhone Number 7 '/4, V., Section <br /> N W 1 O m 7�'Tir�l- 7 Zl b mcle on <br /> IL Type ofWilding(check all theta 1 Lot ft T, �N; REor <br /> PP Y) <br /> I or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> Block a <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of _1 <br /> V /D Town of [ j0/" <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) ! <br /> A. <br /> ❑New System ErReplacement System ❑TrealmentAioldmg Tank Replacement Only 11 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of%umber ❑Permit Tmrsfx b New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com nent/Device: Check all that apply) <br /> N(Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mor n l>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersabTreatment Area Information: <br /> Design Flow(gpd) DesignApplication Rate(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> ,Lon <br /> 17 <br /> � Bs7 9x"7 %9 5 ,69zo <br /> VL Tank Info Capacity in Total 1lof Manufacturer <br /> u <br /> Gdlas Gallas Units <br /> New TaN:s laisting Tanks v o g <br /> aU in h h iLU � <br /> Septic or Holding Tank <br /> Dosing Chamber �V <br /> V 11.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWYS shown on the attached plans. <br /> Plu r s Name(Print) Plum s Si lure MP/MPRS Number Business Phone Number <br /> Plumber's Address(Sheet,City,State,Zip C ) <br /> 0=9 -Tin,151s•j (NtLg�e/W:54gg <br /> VIII.Court e artment Use Onl <br /> Approved /D❑Disapproved $Permit Fee Date Issued Lcsuirng t Sigratae <br /> ZSR 7 ZdVZ <br /> ❑Owner Given Reason Pa Denial - <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> p El <br /> Attarh m cpmpkte plans for the saskan and submit an the Comity Baby on paper oat len than 8 in i 11 im,lu <br /> i <br /> BURNETTCOUNTY <br /> SBD-6398(R. II/11) ZONING <br />