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County <br /> Safety and Buildings Division frlE�l <br /> p S � 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 77 j �� <br /> •,yrs,._ �7. <br /> Sanitary Permit Application State TransacrionNum/bycp <br /> In accordance with SPS 383.21(2),Wis.Adm Code,submission of this form to the appropriate governmental mut GO✓H fy " "vv e w <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different dum in],aiiling address) <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(1)(m),Stars. <br /> 1. Application Information-Please Print AB Information <br /> Pmpe Pwner's Name Parcel# <br /> hlv f/' <br /> Property Ow`nneer's Mailing Address - Property Location <br /> / 6Zj6iile le z/Le Govt.Lot q <br /> City tatef Zip Code Phone Number y., V., Section—L <br /> r,o +� / / �/(ctrcle on <br /> I" 6� 7 #0 N; R 60 E Q <br /> 11.Type of Building(check all that apply) Lot# <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms i S/ub.,diivvision(Name J�((55e-f15 <br /> Block# nn' F�swlt�Ilo+�P)v ci� <br /> ❑Public/Commercial-Describe Use I <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> YFTown of Oq04 4id — <br /> III.Type of Permit: (Checkonlyone box on line A. Complete line B if applicable) <br /> A. New System tlReplacement System g p y g System(explain) <br /> ❑ ❑TreahnenVHoldin Tank Replacement Only Other Modification to Fxistin 5 tem <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 S stem/Com nent/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in_of suitable soil <br /> 19 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersallTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 00 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks 2 0 <br /> v <br /> a U in w rn a V a. <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 plana. <br /> Plum s Name(Print) / Plum s gruduly- MP/MPRS Number Business Phone Number <br /> o5��d nd�� G� 851 gS zis-566-oZo Z <br /> Plumber's Address(Street,City,State,Zip <br /> VITT.Cour /De artment Use Only eN <br /> Permit Fee D p Date Issued Issuing Agent Sign <br /> Approved ❑Disapproved <br /> ❑Owner Given Reason for Denial S `-'�� ✓ �� 3 +/CD <br /> IX,Conditions of ApprovgMeasons for Disapproval p / �a p <br /> Se�dme,E' fro," 7-,,,,4 To !is�lt+r�ry G�ro�S D E ire E I V E <br /> .SEP 0 2 7016 n <br /> Attach to complete plans for the system and submit to the County only an paper not leu than 8{rz s li Rhes size <br /> BURNETT COUNT <br /> ZONING <br /> SBD-6398(R.I Ill 1) <br />