Laserfiche WebLink
Safety and Buildings Division County '' <br /> ` AN as 201 W.Washington Ave.,P.O.Box 7162 2 c Lien v'rf- <br /> mcconscin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 ,1�� '�� <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information <br /> f fanse,AM Z& Tr y <br /> Property Owner's Name Parcel# Lot# Block# <br /> /Vayc /Irs,C'w O D— <br /> Property Owner's Mailing Address Property Location <br /> / 3 o s. Ca.✓o I Cori 7 <br /> City,State Zip Code Phone NumberY4. _Y., Section <br /> /Y/rHd r7 u/S S2j$Sg (circle o e) <br /> II.Type of uilding(check all that apply) T YO N; R ��/ E or� <br /> Q 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name C,MJNum1b�erVi- <br /> State <br /> ❑Public/Commercial-Describe Use rl n r , �. 7 awl d V , <br /> ❑ Owned-Describe Use ❑City_❑Village&ownshipof <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. ONew System ❑ Replacement System ep y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T of POWTS S atem: Check all that apply) <br /> Non-Pressurized in-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Welland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Informatlon: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 1/Se 1 17 6 y3 6vg 915-0 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Took /doe <br /> Aerobic Treatment Unit <br /> Dosing Chamber <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 Signature MP/MPRS Number Business Phone Number <br /> /?t c& Wo i n S 2t� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> dt 7760 f/H.r 3s We e. ws— r�X 93 <br /> =E1 <br /> ment Use Onlsapproved Sanitary Permit Fee(includes Groundwater <br /> a Stamps)Surcharge Fee) ,O/wner Given Reason for Denial <br /> IX.Conditions of ApprovaMeasons for Disapproval <br /> "OCT � � <br /> BURNETT COUNTY r <br /> ZONING <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches In she <br /> SBD-6398 (R. 01/03) <br />