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County nvelf <br /> =.+ Coun <br /> Safety and Buildings Division j <br /> US fit 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> PS +� Madison,Wl 53707-71628753 <br /> Transaction Number <br /> Sanitary Permit Application State <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 Servics. 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# <br /> A&7 lake, i6rot Ale- <br /> Property Owner's Mailing Addres - Property Location <br /> 66 g q & 70 Govt.Lot <br /> City,State Zip Code Phone Number /,, y,, Section Z <br /> 7f fe&) X J SK(r,7Z4 ^ if T9 lc one <br /> w•� J rf� TN; R� <br /> Il.Type of Building(check all that apply) � Lest# ncEoz <br /> I or 2 Family Dwelling-Number of Bedrooms y Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> V Q//J aTown of_ AmitoAJ <br /> I1I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A- ❑New System IKRe lacement System y p y ❑Treatment/Holding Tank Replacement Only ❑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 Oar <br /> IV.Type of POWTS S stemiCom onent/Device: Check all that apply) <br /> ❑Non-Pressurized ht-Ground ❑Pressurized In-Ground ❑At-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 /> DesignFlow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 o c v <br /> New Tanks Existing Tanks IF. - <br /> 8 r2 m <br /> Septic or Holding Tank 7� ryZ470� <br /> Dosing Chamber 6 V <br /> VQ.Responsibility Statement-1.the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) Plu ignature MPiMPRS Number Business Phone Number <br /> 05`3 4M2�� �� 8`J74 <br /> 07 L <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Wel.,/4r I..J 5 8P <br /> VIII.CountyiDepartment Use Only <br /> Permit Fee Dg Agent Issued Issuin Si na t <br /> Approved El Disapproved { G gent g <br /> ❑Owner Given Reason for Denial S �`�'D� V <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEQVE <br /> Attach to complete plass for the system and submit to the County only on paper not less then 8 12 a I I eh size <br /> SBD-6398(R.11!11) AUG 2 2 20% <br /> BURNETT COUNTY <br /> ZONING <br />