Laserfiche WebLink
/„Bv`araEvr County <br /> l,.41 <br /> °^ Safety and Buildings Division a�N <br /> 10$ Irl 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P S P.O. Box 7162 O�-gyp <br /> q y�� Madison,WI 53707-7162 L-�O <br /> Sanitary Permit Application State! r!otdiof <br /> In accordance with SPS 38321(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 Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the PrivacyLaw,s. 15.04(1 m),Stats. r <br /> .J F� yrrc 1C <br /> I. A L k Application Information-Please Print All Information <br /> Property Owner's Name r Parcel#O 7 O <br /> O e/ 1 D o 0 0 <br /> Property Owner's Mailing Address Property LOCO°OG/ <br /> C� r Govt.Lot <br /> City,State Zip CodePhonePhone Number y4 -�y., Section <br /> e J — S/,3 Tcycle one) <br /> �( Type of Building(check all that apply) Lot# _WN, R Eo(!D <br /> A`l or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> / Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ village of <br /> Town of <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> ` - ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Pernit 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 appi <br /> Non-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: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Je 1 , 7 1 Y�27 5's� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> W J U U h N <br /> New Tacks Existing Tanks o g B _ <br /> U rn y v7 iz3 C. <br /> Septic or Belding-Tank O �o <br /> Dosing chamber <br /> VII.Responsibility Statement-I,the andersign assu responsibility for installation of the POWTS shown on the attached plans. <br /> PI b�'s Nanx ) s MP/MPRS Number Business Phone Number <br /> �0&ion P <br /> Plumbe s Address(Street,City,State,Ziq Code) <br /> R��� 131 G <br /> VIII.Co un /Deartment Use Onl <br /> Approved El Disapproved Permit Fee Date Issued Issuing Agent S' <br /> $ QD Q <br /> El Owner Given Reason for Denial 3 -7-S. v ' 3- 16 <br /> DSL_Conditions of Approval/Reasons for Disapproval <br /> f�C�L��dE <br /> AUG 3 2016 <br /> R6 <br /> Attach to complete plan for the system and submit to the County only on paper act less thea 81/2 es in sine <br /> BURNETT COUNTY <br /> ZONING <br />