Laserfiche WebLink
N <br /> /,i 5.7ws- County <br /> :. ''I"r4 Industry Services Division Liu.v n•ems <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> 1 :4* '1 P.O. Box 7162 <br /> '. SAS-Al - 27�� <br /> ��. ,.;s; Madison, WI 53707-7162 <br /> < ..0 _ 1.'Lt c 3 <br /> State Transaction Number <br /> Sanitary Peinlit Application . <br /> In accordance with SPS 383.21(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 mailinn address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ty P{goi W 1 14° 6 n Q <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information /11 a(/Cron Li C /?a• <br /> Property Owner's Name Parcel# <br /> Parcel <br /> # -;t`..0,_is-- 3S-.S'os-GO, <br /> .JGy //a 0-rns . - CIS000 <br /> Property Owner's Mailing Address ,o Property Location <br /> /3/d J4'7a.r5h4// /� t/C Govt.Lot 3 <br /> City,State Zip CodePhone Number IA, Section 3S� <br /> ,5 f' P/t k ( W S J O 7 I (circle one) <br /> T 1-0 N; R /,S E oe <br /> IL Type of Building(check all that apply) Lot# <br /> I or2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Couunercial-Describe Use ❑ City of • <br /> ❑State Owned-Describe Use CSM Number El Village of <br /> 2 Town of jet G IG 5 o v' . <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. pp New System <br /> y CI Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other N[oditication to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner - <br /> IV.:pype of POWTSSystem/Component/Device: (Check all that apply) <br /> ❑Noii Press zed In-Ground 0 Pressurized In-Ground ❑ At:Grade 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> jii I-foldmgTank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V<Dispersal/Treatment Area Information: <br /> DesignFld i,(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> yso / 5'3 6 -a 93 <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units v o <br /> New Tanks Existing Tanks 9 o 2 ro <br /> a`/r_ rn m C4 u-U 0 <br /> Septic or Holding Tank nDOa /OBO / Jell14 /� <br /> Dosing Chamber- 1 :)t <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 /> /2 r L4 4 km s /G�� 1�:��s I 7/s=��O6—___ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G)'7 7 6 D 4_,/, ?.5 fri/-e S 5?It', lily S7!85 3 <br /> VIII.County_Departmetit Use Onl <br /> 0 Approved ❑ Disapproved $ennit Fee dat7 Date Issued t Sign a _,..,•••i+ <br /> 0 Owner Given Reason for Denial 376 75 9713/0 G•�j� <br /> IX.Conditions ..roval/Reasons for Disapproval ° --- —" E <br /> OVE <br /> 1 SEP 0 1 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 ira x 1I inches I size <br /> Burnett County <br /> Land Services Department <br /> SBD-6393 (R0313) .114 177Ti f *---2 1' <br />