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minty "e jC <br /> *"=' `=;_ Safety and Buildings Division r/{/��" <br /> i Q S 3 ! 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filed in by Co.) <br /> P$ r^t Madison,WI 53707 7162 <br /> Sanitary Permit Application Stoic Transaction Number <br /> In accordance with SPS 383.21(2),Nis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fortes for state-owned PO\VfS are submitted to Project Address(if different than toiling address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.Ii.04(q(m},Slats. <br /> 1. Application Information-Please Print Ail Information <br /> Property Owner's Nam/ee� Parcel <br /> ;. W it <br /> y r rarZ Z�D�iS=11�f1IF-ml4otoop <br /> Property Owner's Mailing Address Property Location <br /> f@� <br /> e <br /> 9!5��/y 4? W.4i GovL Lot <br /> City,State Zip Code Phone Number y, 1 <br /> /y Section <br /> AmLr ,w 5y8.&O G/Z-Z/o—ti�SG tr cane) <br /> U.Type of Building(check all that apply) Lot# T !V N; R I trolE a <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block lr y f�rV <br /> ❑Public/Commercial-Describe Use <br /> • ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of J 1," <br /> I%Townof ;I-T�tGFsc <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System (p.Re laeement System ❑TreatnumMoldin Tank Replacement Only ❑Other Modification to S (explain) <br /> yr P Y g P Y Existing System l P ) <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 POINTS S stemlCom nent/Device: Check all that apply) <br /> OrNon-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(r:xplain) Q 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(sf) System Elevation <br /> y5o 7 6170 - I <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> ` Gallons Gallons Units P o <br /> New Tanks Existing Tanks n c u E y a a <br /> a U m y rn 1--a c. <br /> Scptic or Halding Tank• <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume 2Tensibility for installation of the PONVTS shown on the attached plaits. <br /> Plum s Name Plumber's S' MPiMPRS Number Business Phone Number <br /> o�i� D`4�LCf:� �� f�SI4S jt/$`54G—0Z0Z. <br /> Plumber's Address,(Struct,City,State,Zip Code) l <br /> 27z2v -arnti4k=5^1 1 t4gs/4?^ t,J� s�l8p <br /> [II. n!ylDepartment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Si store <br /> ❑Owner Given Reason for Denial S 376- (1 � - '� <br /> IX.Conditions of Approval/R,eaasons for Dump ravvat <br /> �L/P✓ ,(�Is%.v %o e L.vsO�.cll{� r Grt/rr Ce�ls <br /> �IiAAI� /Irfrll v yr`00- ///�lC Dl�� ✓Du,rdl �vr a[C1, ___) ECEIVEE <br /> Attacb to complete pram far the sestem and submit to the Count-onb•on paper not less than 8 lwpches in acre <br /> SBD-6398(R.I1iI1) AUG 2 8 2017 <br /> BURNETT COUNTY <br /> 7rlkllklr-1 <br />