Laserfiche WebLink
7— !`, ',. Industry Services Division County Howell"/J <br /> -, <br /> ;,;", B ';.•, 1400 E Washington Ave <br /> 1;1 �% ,`s, P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI53707-7162 SricN --22,;-7 7 <br /> `h` 'nti�j J . <br /> cSi-<�:z- 6-7 ��f-3�/7C� <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 <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 Privacy Law,s. 15.04(1)(m),Stats. _ J �/ �/ <br /> I. Application Information—Please Print All Information 27//' JC)/�N /ei <br /> Property Owner's Name Parcel# <br /> g0/2 <br /> delev;994n , octig-119-16—o3—S of-03-011oz <br /> Property Owner's Mailing Address Property Location <br /> i4'2 I, ) Yu kO/J(/�i t Govt.Lot <br /> City,State 4 Zip Code Phone Number 3 <br /> 7 D c/ /.. /�, Section / <br /> Ua e e /12 863M tc cle on <br /> II.Type of Building heck all that apply) Lot - T 3°I N; R /i E a <br /> Qri or 2 Family Dwelling—Number of Bedrooms y y Subdivision Name <br /> Block g <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> (I'Town of /Nee <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> cgt New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of PlumberList Previous Permit Number and Date Issued <br /> g 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound 24 in.of suitable soil l 'Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 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 /> 606 14 hev 4w 9q6 <br /> VI.Tank Info I Capacity in Total T of Manufacturer <br /> Gallons Gallons Units g <br /> New Tanks g' U <br /> Existing Tanks <br /> 6..U to w fA C% a C., <br /> Septic or Holding Tank -e', <br /> Dosing Chamber ,`cz) 119155 1 WI/('/ Y <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum cr's Name(Print) Plumber's '_n ro MP/1�1PRS Number Business Phone Number <br /> .* i,19 �%� 86l 9 Jam' 7/5=`r -6�Z <br /> Plumh�r s Address(Street,City,State,Zip Code) <br /> 6 81 ,twiw a le At kJe6 era 5 °&9 3 <br /> VT.County/Department Use Only <br /> 00 <br /> ,ni Approved 0 Disapproved Permit Fee Date Issued Iss in Age Signa <br /> ❑ Owner Given Reason for Denial q a5 + f/7a �'�� <br /> IX.Conditions of Approval/Reasons for sapproval <br /> (11 ee+ k 11 Se--f-b z 4 C K-4 i 3 ` <br /> --- ECEOVE,----) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1r2 s 11 ini It re <br /> MAY 1 0 2022 <br /> SBD-6398(R.08114) Burnett County <br /> Land Services Department <br />