Laserfiche WebLink
Safety and Buildings Division County <br /> iseonsin 201 W.Washington Ave., P.O. Box 7162 <br /> Madison,WI 53707-7162 Site Address <br /> De artment Of Commerce / /�r <br /> Sanitary Permit Application Sanitary Pprrnk Nu �mber l �J �} <br /> In accord with Comm 83.sec Wis.Adm,Code,Privacy <br /> L information don you provide <br /> maybe used for Seco ses Privac Law 15. 1)(m ❑ Check if Revision <br /> I. Application Information-Please Print All Information <br /> State Plan I.D.Number <br /> Property Owner's lame <br /> ® Parcel Num r <br /> �a-75 /5 - So 0 <br /> Property Owner's Mailing Address L 7 — A <br /> / Q Property L,orc�ation <br /> City.State Lf �' Sf/r�'A;S T N.R�S <br /> Zip Code (J Phone N ber LotNumber ylgr"ej Block Number <br /> Subdivision Name C�SM Number <br /> IIs/.Type of Building(check all that apply) <br /> �'$ $ !� ✓YDS� ��UQ''hf.�'i! <br /> XQ 1 or 2 Family Dwelling-Number of Bedrooms []city <br /> /❑\Public/Commercial-Describe Use ❑Village <br /> ❑State Owned ownshi �}G� <br /> Nearest Road <br /> 570 <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to �ForY <br /> unt rue <br /> stem TankOnl Exis' S stem <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> l V.Type of Permit: (Check all that apply)(numbering scheme is for internal trse) <br /> 44 yNon-Pressurized In-Ground 21[1 Mound <br /> 47 11 Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass <br /> B 51 El Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Vis ersavrreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application <br /> Required Percolation Rate System Elevation Final Grade <br /> 30/^ qu Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> X35 <br /> VI.Tank Info Capacity in Total Number <br /> Gallons Gallons of Tanks Manufacturer Prefab Site Steel Fiber Plastic <br /> New Existing Concrete Constructed Glass <br /> Tanks Tanks <br /> epde Holding Tank 0b <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for:,installation of the POWTS shown on the attached plans. <br /> PI her's Name(Print) Plumignature ber's <br /> t P/MPRS Number BusinessPhoneNumber <br /> :::: <br /> Plumber's Address(S et,City,State,Zi Code) <br /> o <br /> Count /De artment Use Only <br /> Approved ❑ Disapproved ta (' t rnuKtdwater Date Issu Issuing nt Sig to ( tamps) <br /> ❑ Owner Given Initial Adv �0 ® y b <br /> Determination I (� <br /> IX. Conditions of Approval/Reaso isap 00° <br /> C / <br /> BURNETT COUNTY <br /> ZONING <br /> Attach complete platy(to the Couotl only)for the ryatem on paper not Iesa then 81/2 x Il inchn In size <br /> SBD-6398 (R. 05101) <br />