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County <br /> Industry Services Division f3(ev v! <br /> ,' t) � 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> 4 Ps P.O. Box 7162j� <br /> ' •b.. Madison,WI 53707-7162 -X)r3 <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 G Ou 4'We tv <br /> is required prior to obtaining a sanitary permit. Note:Application Bonus 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 a V 7s <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Slats. <br /> I. Application Information—Please Print All Information G, ',l�le ✓ �zI o ev <br /> Property Owner's Name Parcel# <br /> �t 07-44aA-yd -/44`07-Sis- <br /> � 26 J9�d-ev.; Mo - o/7aaE� <br /> Property Owner's Mailing Address Property Location <br /> k -I AV" t e t t'G IY_ Govt.Lot <br /> City,State Zip Code Phone Number y,, S6, Section <br /> A 5Y �GsN ' /y�Al Ss/69 T Z149 N; R &(circlEa�eone) <br /> ❑.Type of Building(check all that apply) � Lot# <br /> ® t or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> Town of ©cL lee the <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' New System <br /> y ❑Replacement System ❑ 'I'reanmenr%I Inkling 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 <br /> IV.Type of POWTS System/Component/Device: (Check all that a Iv) <br /> ' Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grudc ❑ 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(gpdssal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> ?ee , s f) Disper Goe Goa `i3.s <br /> Vt.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons l'nits o '� <br /> y u <br /> New Wanks Existing Tanks w <br /> H <br /> 2 a <br /> a <br /> c, U in ti vt iL U . <br /> Septic or Holding Tank <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 /> Plumber's Address(Street,City,State,Zip Code) <br /> I-e-6.5/ram <br /> {{{VIII.County/Department Use Only <br /> pli Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signal re <br /> ❑ Owner Given Reason for Denial y; c3/ 0 �Q <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> nrp-% ECEIVEnn _ I <br /> Attach to complete plans for the system and submit to the County oily on paper not less than 8 va x incl insAUG 0 4 2016 <br /> SBD-6398(R0313) BURNM COUNTY <br /> ZONING <br />