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sy <br /> JA .x Safety and Buildings Division County 6u C n e>ti <br /> 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison, WI 53707-7162 / , ,(/ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 353.21(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 1 <br /> purposes in accordance with the PrivacyLaw,s.15.04(I)(m),Stats. L i n C o)n 5 <br /> I. Application Information-Please Print All Information <br /> Properly Owner's Name Parcel# <br /> s-EC men � MAr o�-OHO- a-4o-/6-3a-S <br /> S�2a»n �� n - - oaf000 <br /> Property Owner's Mailing Address Property Location <br /> a14-�90 N a3 rd Ave Un;-k ',) "77 Govt.Lot <br /> City,State /� Zip Codec Phone Number n '/., Section 3a <br /> A Z 2508 5 T WO N; R 1 b �circleoir<) <br /> II.Type of Building(check all that apply) Lot# <br /> X,or 2 Family Dwelling-Number of Bedrooms 3 3 Subdivision Name <br /> Block# SEFFAIES ESTATE <br /> ❑PubliclCommercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Dr'fown of 00.K I G n d <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, KNew System ❑Replacement System <br /> Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. El Permit Renewal El Permit Revision ❑ Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> rI�V.`T a of POWTS S stem/Com onenUDevice: Check all that apply) <br /> Ienlvon-Pressurized 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: 3z Du: K y P/vs ch r» rS &J/ Z o P e <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> q-Sb 0-'7 ca 3 GS A A 9 8 . 0 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 54 <br /> New Tanks Existing Tanks 0 C "pp u A -9 <br /> a U <br /> Septic or Holding Tank I OO O 1000 CQ»e rer <br /> TQC <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assuvoresponsibility,for inst ation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' ignatwe MP/MPRS Number Business Phone Number <br /> -f't- ,.. 5 3v}}err; PCs 65*1) 7/6--63y-8) 7(e <br /> Plumber's Address(Street,City,State,Zip Code) <br /> )4,3 Y(o tJ .5-W-t Qo a ci <br /> VIII.Couny/Department Use Only <br /> Approved ElDisapproved Permit Fee 9, Date Issued Issuing Agent Si e <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Lei ECEI U E <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8112 x IIU <br /> in Side n 28 <br /> 2015 <br /> SBD-6398(R. 11/11) BURNETT COUNTY <br /> ZONING <br />