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County <br /> Safety and Buildings Division <br /> D S max= 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> P {'� Madison,Wl 53707-7162 <br /> S 5$8715 <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 mit <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 Seines. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m).Stats. I <br /> 1. Application Information-Please Print All Information (� <br /> Property Ow is Na a Parcel# <br /> J �-2- G-ly- <br /> Property Owners Mailing Address view <br /> p�"ew - Property Location <br /> 7 0� `r I Govt.Lot <br /> City ate /lJ� �J Zip Code Phone Number Y. , <br /> t'Vr/.I� V' / y/ 'Z / Section <br /> 71/tiLtt�/ 7� trete on <br /> /7 i7 T.�N: R_WEotw <br /> It.Type of Building(check all that apply) � Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# 1. <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of _ <br /> V G / Pr f KTown of �G01T <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A_ ❑New System y 11 Replacement System �Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 11 Permit Renewal ❑Permit Revision ❑Change of Plumber 13 Permit Transfer to New <br /> List Previous Permit N her and Daze <br /> Before Expiration Owner s <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mond?24 in.of suitable soil ❑Mound<24 in.of suitable imil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVYreatment Area Information: <br /> Design Flo ) Design Soil Application Ratc(gpdsf) Dispersal Are Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 6Jiro70 11(YIe 1 <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a'�, u <br /> New Tanks Existing Tanks u o u a m <br /> a U <br /> Septic or Holding Tank �y�y,� � I"_V 1 <br /> JE <br /> Dosing Chamber <br /> VQ.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plaits. <br /> Plum s Name(Print) // Plumbc aturc MPrMPRS Number Business Phone Number <br /> g D�knde�' �� BSfgS S6G-40ZOZ. <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> I.County/Department Use Only <br /> Approved El Disapproved Penni-t7F,ee( Date Issued / Issuing Agent Sign <br /> ElOwner Given Reason for Denial S� / c>•DO 7- 1q-,11,, <br /> IX Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not las than 8 la x 1 t inch is <br /> min U V 16M <br /> SBD-6398(R. 11/I1) JUL 13 2016 <br /> BURNETT COUNTY <br />