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Safety and Buildings Division County <br /> Bt.xerleY4' <br /> :7, 0� � 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in byjaddress) <br /> \ pS Madison,WI 53707-7162 <br /> 550'832 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),W is.Adm.Code,submission of this form to the appropriate governmental unit �� z <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 <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 gm),Stats. -785­1 Co Roe FF <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#a 7 o Fr-A-3 9-1 <br /> Lx /0/^11 Pt f er.r e,, -36 0049— 617 600 1016-3367.6(-6,n <br /> Property Owner's Mailing Address Property Location <br /> D A IL1/• C a�G m /JI Govt Lot <br /> City,State Zip Code Phone Number �6 y -y, Section 7 <br /> GLI t C w w Fw //j tti 1 `4 Tal Q T -?47 N; R /B circle onE orQb°e]]..,, <br /> IL Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> L/. 1 P39 VTown of { �en erl <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A- ❑ New System ,Replacement System ❑TreatmenUHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Chani e of Plumber iD Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> [%'.Type of POWTS System/Component/Device: Check all that apply) <br /> i�. Non-Pressurized In-Ground C1 Pressurized In-Ground [Iyi At-Grade Mound,24 inofsuitable soil ❑ Mound<24 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow( Design Soil Application Rate(gplst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units U j <br /> New Tanks Existing Tanks E <br /> Septic or Holding Tank /000 Awo <br /> Dosing Chamber fa00 GvQ <br /> VII. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POyVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbers Signature MP/MPRS Number Business Phone Number <br /> Z e/.- /0,p%f., r /21-6� J01JB"-/ pis- gbG-4�s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a1776D Al–y -Kf­ z4e6sfr.- A— -5 'Y993 <br /> VIII.County/Department Use Only <br /> A'AApproved ❑ Disapproved Permit Fee Date Issued Issuing Ag t -_nature <br /> ❑ Owner Given Reason for Denial 1 3 -7 -" <br /> IX.Conditions of Approval/Reasons for Disapprovalf� I E <br /> DIIiLrL, V <br /> AUG 6'2012 <br /> Attach to complete plans for the system and submit to the County only an paper not less than 8 12 x 11 inch n <br /> BURNETT COUNTY <br /> ZONING <br /> SBD-6398(R. I I/l l) <br />