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,, .,xRiq:4, County <br /> �?( -r; Industry Services Division �u V'��'� <br /> t a. r�3 <br /> �r; S3� 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> �; P ! P.O. Box 7162 <br /> sS Madison,WI 53707-7162 SA ?J—I C-1() <br /> bUt o1 aS)-1st- -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 yA— <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 ) 7 3). <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. /1,.. RelI. Application Information—Please Print All Information <br /> Property Owner's Name Pa� l#_ j_ y0_p/..—.'6,-j'-- <br /> KiAvt lei ddo at"3 -ei,ti600 <br /> Property Owner's Mailing Address p ` Property Location <br /> 7))0 /ii0 y R.✓"C�C L 11 ` Govt.Lot 7 <br /> City,State Zip Code Phone Number y y,1, <br /> , Section 3�C <br /> Ed 114 4 jr) /✓ 575'9 T 4/0 N; R /7 irclEe ore <br /> II.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling—Number of Bedrooms 3 Z Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of _�,c_ <br /> V. ID f a,46 �Townof 5ce /l <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. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner . ..sli/ 6 S/ <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> (tion Pressdiized 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(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 10 -0 ,0n q 0 0 933 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons UnitsV- . <br /> New Tanks Existing Tanks '` : 2 <br /> c, U cn h in c(7 C. <br /> Septic or Holding Tank /660 /440 / <br /> 41 f",5Y,,---- A—' <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Re'c fC //0/4 5 % h44_,/:-- 1)s-,9›—/ 7`$ e- 's-, <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776? lbw t _S'Lit-e- �'x`-e� i -5-9 e,'3 <br /> VIII.Coon /Deo artmtnt Use Only / <br /> Permit Fee Date Issued Issuing Agent Signa e / <br /> `• Approved ❑ Disapproved $ 2 76' <br /> B p <br /> ❑ Owner Given Reason for Denial J ` 7' /9 /b ,4 <br /> IX.Conditions ofApprovva1l/Reasons for Disapproval <br /> R/C11/ea /JQ,g fl1Jevzic 1K = ?go.) ADPROVEDECEOV ETh <br /> al <br /> D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2;.11 in_ es iUL ' V � <br /> BURNETT COUNTY <br /> SBD-6398(80313) ZONING <br />