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. , <br /> Safety and Buildings Division Conary V(W( <br /> )a, as p rI 201 W.Washington Ave.,P.O.BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> L $ :; Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction NNum <br /> bct <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 6011,11 / eL)Ie w <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. J / <br /> I. Application Information—Please Print All Information /a/- � �>< <br /> Property Owner's N eParcel# <br /> w�l .5 <br /> �///��� <br /> Property Owner's Mailing Address --J Property Location <br /> 29$K CA�Nd�1 Axe xe y Govt.Lot <br /> City tate Zip Code Phone Number Ay A <br /> /,/,//1w ] �F�7 L1 h, Section <br /> / /'r V 4- &Z-2,V- 71 cucle o <br /> 11.Type of Building(check all that apply) Lot# T v N; R E r <br /> I or 2 Family Dwelling-Number of Bedrooms Z /0 Subdivision Name , / <br /> Block# S V�! <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> XTown of T4Gk54f1 <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, qrNew System ❑Replacement System ❑Treatment/HoldingReplacement Only ❑ Other Modification tion 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 S stem/Com nent/Device: (Check all that apply) <br /> DFNon-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(gpd) Design Soil Application Rate(gpdsO Dispersal��Required(so Dispersal Area Proposed(sf) Sygjem Elevation <br /> 64 940e 96. 9V tv <br /> Vt.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units E U d u <br /> New TacksExisting Tanks <br /> n <br /> a U rn t;; m U. U C. <br /> Septic or Holding Tank m cal p�V 5 <br /> IY <br /> Dosing Chamber V <br /> VII.Responsibility Statement—f,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) Plumber' acme MP/MPRS Number Business Phone Number <br /> o9g o nit ems- $Sl gS 11,5-56G -o z.o z <br /> Plumber's Address(Street,City,State,Zip Code) / -/ <br /> F.7ZZo 741'7, -xw t;r wel.,Io" l.i r 5 9F <br /> VRI.County/Department Use Only <br /> Permit Fee Date Issued Issuingr:7 <br /> Approved ❑Disapproved $ 00 <br /> ❑Owner Given Reason for Denial 7s - �a a a��s <br /> //Jawf� <br /> IX.Conditions of ApprovaVReasons for Disapproval <br /> pr--, ECEIVE <br /> Attach to complete plana for the system and submit to the County only on paper not less thio t/i t t si <br /> BURNETT COUNTY <br /> SBD-6398(R. 11/11) ZONING <br />