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County ` <br /> Safety and Buildings Division U <br /> D$ hl 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1 PS ,;j Madison,WI 53707-7162 <br /> .r3 e, a1S J <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 <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> 1. Application Information-Please Print All Information <br /> Property Owners Nam ./ Parcel# <br /> CN <br /> Property Owner's Mailing Address Property Location <br /> d yIg6 Ge i7d!nl�O►' Govt.Lot U <br /> City,State Zip Code Phone Number ' '/., Section 3 <br /> V V ek/ p r 5 —W -7 !� ircle on <br /> 7iv O T�N; R �(s Ead) <br /> 11.Type of Building(check all that apply) +� Lot# <br /> �l or 2 Family Dwelling—Number of Bedroomsy Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of P 7/ A Town of /jam ejeiA AI <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System y El Replacement System CKTreatmenUHolding 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 Date Issued <br /> Before Expiration Owner (q V I <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> FNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable so' <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsl) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> . 7 4as ' 9-Ar <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v <br /> New Tan <br /> Fs Existing Tanks .P- u <br /> V y <br /> V - m <br /> � L rn 2 rn tz CJ a <br /> Septic or Holding Tank A <br /> Dosing Chamber <br /> VII.Responsibility Statement—1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) / Plumb ignaturc ��, IMPtMPRS Number Business Phone Number <br /> o�i5 D�4 (ems /�aY/ $SJgZ)7 1-1/15-566 -oZo Z <br /> Plumber's Address(Street,City,State,Zip Code) / / <br /> Z 7Z207�11�'�/ --ICs J;CI <br /> VIII.County/Department Use Only <br /> ® Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signa re <br /> ❑Owner Given Reason for Denial S 3 7,5-, ;7 <br /> IX.ConditionsofApprovalfReasons for Disapproval <br /> f / <br /> TPGL �Nk Je{Putt- <br /> np EcEuvE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IQ x l l nze JUL 15 <br /> 2016 <br /> 6 <br /> SBD-6398(R. I I/11) BURNETT COUNTY <br /> ZONING <br />