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„sfvarjEti County <br /> Safety and Buildings Division w(,r n+ f'f <br /> 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> t 1 PS ”, Madison,Wl 53707-7162 <br /> `N `� `✓° 1 558 SZR <br /> Sanitary Permit Application StateTransaOctionN,u�mberr <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit G- ✓.e L 6 7 P`Lolefb <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 Safery and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Slats. 2 �am''/- „35/ <br /> 1. Application Information-Please Print All Information 72 8 J <br /> Property Owner's Name Parcel# 020.4333-0(0-,1b0 <br /> , Gr '(c11lCe Y✓ -f <br /> roperryOwner'sMailingAddress s Property Location jjlQ <br /> '108 Stale 3591eL�, <br /> Govt.Lot_y__ <br /> City,State Zip Code Phone Number S <br /> f� '/., Section�3 <br /> W 'Apr S�p /3 (circle on <br /> It.Type of Building(check all that apply) Lot LotR��Eo� <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑ <br /> Pub]is/Commercial-Describe Use <br /> ❑Ciry of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of t/ / <br /> XTownof aQf�rEMC <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. El Permit Renewal 11 Permit Revision ❑ List Previous Permit Number and Date IssuedChange of Plumber ❑Permit Transfer to New � / " <br /> Before Expiration Owner a u /-7 a ro <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) 3, <br /> K,Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 inof 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(sf) Dispersal Area Proposed Is f) System Elevation <br /> ov E -5.4-, .,4009 Fr % /00, 00 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v <br /> V <br /> New Tanks Existing Tanks <br /> ( ' FS <br /> Septi r Holding Tank X •7 d ( I k S r (ry <br /> Dosing C>pfibcr i FS-.' X <br /> VII.Responsibility Statement- 1,the undersigned, ssume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum er's Signature // MP/MPRS Number Business Phone Number <br /> (S %. T r- c 6� `_6� saa ei 1711- X66- oe <br /> P umber's Address(Street,City,State,Zip Code) <br /> � 'S (�� r j?d P Qk-4- SvP4s <br /> VIII 'oun e artment Use Only'Approved /D❑ Disapproved Permit Fee Date Is-suueed`/ Issuing n tgnature <br /> ❑Owner Given Reason for Denial <br /> IX.DConditions of Approval/Reasons for Disapproval <br /> fe✓0"n If <br /> F,4r CCu+� aF l.p la..� oNI y( �((� M <br /> Soil En <br /> A(ayr, il�{f ,yf�y 3'�1{g B: nD llolvJ8 V <br /> Attach to complete plans for the system and submit to the County only on paper not less than 9 ui x 11 inc n <br /> JUL 2 7 <br /> SBD-6398(R. 11/11) BURNETT COUNTY <br /> ZONING <br />