Laserfiche WebLink
yt':•$-.' vf., County^� <br /> 7 '-< ''`,$;"A Industry Services Division />t'`r''''e <br /> li— <br /> ?Y ':';,;::i: ,,. . 1400 E Washington Ave <br /> - <br /> �) 9 Sanitary Permit Number(to be tilled in by Co.} <br /> P.O. Box 7162 cyr t 1-23_15,.� p <br /> �� ��;:,-;;,:-�✓;�. Madison, WI 53707-7162 /� .'')j I.� d <br /> 14 <br /> ~' State Transaction Number <br /> Sanitary Peinit 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 POWVTS 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 `q r1'6 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information [�C �S G/e /?� <br /> Property Owner's Name Parcel# <br /> 07-40_,1-ya--, —d6—S'oS= o& 6 <br /> /or+, R/i_Gr o f ty C' <br /> Property Owner's Mailing Address Property Location - 46 /64 1365'3 <br /> AQ 130)( &417 Govt.Lot to <br /> City,State Zip Code Phone Number / y,, Section a 6 <br /> 2-14 G/ 5141 Q J (circle on <br /> irV <br /> IL Type of Building(check all that apply) Lot# T 4/O N; R /6 E o <br /> tX I or 2 Family Dwelling-Number of Bedrooms Subdivision Name • , <br /> Block# <br /> • <br /> 0 Public/Conimercial-Describe Use <br /> V, 3 t? 5;2 ❑ City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use Oa �a •�, <br /> Z Town of A� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Pennit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 2•3 I ' Lp lag 11 <br /> IV..Type of POWTS:System/Component/Device: (Check all that apply) <br /> Non Press zed In-Ground ❑ Pressurized In-Ground ❑ At-Grade El Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑IEfaldmy Tarik ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V..Daaspersal/Treatment Area Information: <br /> Design*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Re wired(sf) Dispersal Proposed at) System levatior� <br /> e v - • "7 Lfa Q r/'5 2' Z{5 U s . <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units o '" o <br /> New Tanks Existing Tanks o 73P. 'A 'a5. uc,U in y rn (.7 a..Septic or Holding Tank 70 G Q /efi G a / Th ' Y a 7tO x <br /> Dosing Chamber_ 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)ri/ P lumber's <br /> -SignaDture )MP/M-PRRSS Number Business PhoneNumber/ r <br /> le/GAG /7 of /6/H c / L 14A*,,... r ),i.5 J I 7/.cf 6 —9,' 7 <br /> Plumber's Address(Str et,City,State,Zip Code) <br /> 77(o N....-, 35 -y-e-67W. w1 S'Y s' <br /> VIII.County_/Department Use Only <br /> Permit Fee Date Issued i ing A nt Sill <br /> _ <br /> Q Approved ❑ Disapproved $� ��/���� <br /> 0 Owner Given Reason for Denial <br /> DC Conditions of Appr val easons for Disapproval C i U V I <br /> ►l(e6- A l( ✓�Vk t strtie, 1 .r` cn ti) <br /> 1 MAY 15 2023 <br /> D._ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/s s it inche jg size <br /> Burnett County <br /> Land Services Department <br /> "' <br /> SBD-6398 (R0313) 7-- 73c16 114.F' <br />