Laserfiche WebLink
Court <br /> Industry Services Division JjC4 <br /> r n-e ff <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P P.O.Box 7162 S�o�o X60 <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number v4 <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 fors for state-owned POWTS are submitted to Project-Address(iiff different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary _1 <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. <br /> 1. Application Information-Please Print All Information )?A to A&V el r <br /> Property Owner's Name Parcel# NO d rl <br /> �Gtr•ts eeltl ezoftd dy&g0do <br /> Property Owner's Mailing Address Property Location <br /> /DD 93 Al, <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> '/<, '/., Section <br /> /G In N Sfti tf � T 'rilO N; R /.f(circle E onto <br /> 11.Type of wilding(check all that apply) <br /> Lot# - <br /> 1ortFamily Dwelling-Number of Bedrooms 3 ? SubdivisionName <br /> Block# /�-r+•'+ " <br /> ❑Public/Commercial-Describe Use <br /> 11 city of _ <br /> ❑State Owned-Describe Use CSM Number ❑ Village of _ <br /> Town of Joe. J d +n <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I�New System y El Replacement System ❑Treatment/Holding Tank Replacement Only El 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 Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> BJdNon-Pressurized In-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 /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> ef,j--o . �7 G 4e 1*7 1 G.s-'i. 6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a v u <br /> New Tanks Existing Tanks •iO c u a y y <br /> a, <br /> C rJ -✓� r �i V 6. <br /> Septic or Holding Tank -O �OS.D }N F•%r`� e✓ ./ <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 /> /7. <br /> e-le Jyo /c� ✓ dJ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7a o /9:.�) 6,s�4 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved $eriitt Fez Date Issueed Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> p ECENE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8112 z I I in is ui,. <br /> SBD-6398(110313) BURNET(COUNTY <br /> ZONING <br />