Laserfiche WebLink
CCMPU`MRlSCANN <br /> ED <br /> County <br /> `N, Industry Services Division (A y <br /> S ; 1400 E Washington Ave Sanitary Permit Num er( filled in by Co.) <br /> t PS • P.O. Box 7162r�Y7�1 c— <br /> z-.`t � ' Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,subtrissionn of this form to the appropriate govemtnental unit 9.,l 0-� "_cq <br /> is required prior to obtaining a sanitary permit Note:Application forms for stale-owned POWTS are submitted to Project Address(if different than mailing addre ) <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([)(an),Stats. 676"1 <br /> �.�. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name <br /> Parcel a�_�`y o -/t: -!��S-1X_DA hit, ?h :l/: J oc�5-000 <br /> Property Owner's Mailing Address Property Location <br /> /3 A19 .Sti [HQ do&,A Xr,- #V E- Govt Lot <br /> City,State Zip Code Phone Number 'b, Section.7_ <br /> N" Zt M Al .�S�m V (circle one) <br /> QT 40 N; R_ Eo <br /> [� � <br /> .Type of Building(check all that apply) Lot# <br /> Ior2Family Dwelling-Number ofBedrooms r7P SuhdivisionName <br /> ❑Public/CommBlock#ercial-Describe Use ❑ City of <br /> ❑ State Owned-Describe Use CSM Number ❑ Village of <br /> JKTown of Q4W4,w40t9 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Replacement System <br /> ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision <br /> ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date 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-Gmde ❑ 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(so Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o o <br /> New Tanks Existing Tanks <br /> rn <br /> Septic or Holding Tank /bad /GOC <br /> Dosing Chamber /aQ �ma <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Pain/t) Plumber's Signature MP/MPRS Number Business Phone Number <br /> � ,/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776 O 3� �v�b s><Y W _ 8 r 3 <br /> VIII.County/Department Use Only <br /> Approved 11Disapproved Permit Fee 0 0 Date Issued Issuing Agent Sign r <br /> L1 Owner Given Reason for Denial <br /> g37s 7-ZI-16 <br /> _b�' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEIVE <br /> Attach to complete plans for the system and submit to the County anly on paper not less than 8 112 x 11 i es i izJUL 2 0 2016e <br /> SBD-6398(R0313) <br /> BURNETT COUNTY <br />