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County <br /> ��.t Safety and Buildings Division el <br /> 1 s `Ury 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(tv be filled in by Co.) <br /> P-1_ <br /> -7162 A, - 17 -s <br /> 'V <br /> Sq 5O L-1 <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 unit a9 3 -7 1 "' "h/ <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 Servics. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#O O 8 <br /> © / <br /> ,, /7 / <br /> Property Owner's Mailing Address D / Property Location <br /> Q 25-6 / /1�t �d Govt.Lot I� <br /> City,State Zip Code Phone Number _ ya, Al W �14, Section�� <br /> t q �q (circle one) <br /> I11.""Type of Building(check all that apply) <<vv Lot# T d,-N; R E <br /> r 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Comriiercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM`Nu�mJber ❑ Village of .J _ <br /> Y Ot a� Town of *All e' S <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 6L stem ❑ Replacement S <br /> � �New S stem y p y ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil X-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(s f) Dispersal Area Proposed(sf) System Elevation <br /> '�o �C-_D �D . 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks y o u 2 Y p q <br /> Septic or Huldiog-Tenk <br /> Dosing Chamber <br /> VII.Responsibility Statement-f,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si nature MP/MPRS Number Business Phone Number <br /> Plumb is Address(Street,City,State,Zip Code) <br /> VIII.County/ e artment Use Only <br /> '�A(Approvcd ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> 375 s -IS -►� <br /> IX.Conditions of Approval/Reasons for Disapproval E C E I V <br /> ID <br /> MAY 15 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 x 1 ches in size <br /> BURNETT COUNTY <br /> ZONING <br /> SBD-6398(R. 11/11) <br />