Laserfiche WebLink
i <br /> Coun <br /> rye F:l Industry Services Division <br /> 1400 E Washington Ave Sanitary Permit Number to be tilled in b Co.) <br /> P.O. Box7162 �� /i /-7� y <br /> Madison,WI 53707-7162 L ` ,4 I <br /> Sanitary Permit Application state Transaction Number <br /> In accordance with SPS M3.21(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 Safey and Professional Servies. Personal information you provide may be used for secondary .- <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Slats. L1G M.ASAvt �G�" <br /> L Application Information-Please Print All Information <br /> Property Owner's Name I _ Parcel N <br /> eafAerlyle lc�ti 07-in 5a�o�S-3�- Sos <br /> Property Owner's Mailing Address Property Location <br /> Ve(o L✓GITLNVI<w C/Ncle Gow.Lot S <br /> City,State Zip Code Phone Number Section 36 <br /> -5E. W&t�RleGl Sod63 (circle one)- <br /> U.Type of Building(check all that apply) Lot# T L/o N; R �S E oCY <br /> K I or 2 Family Dwell hjg-Number of Bedrooms ✓ , Subdivision Name ph,;P.*F ileq - <br /> Block V. 94 Pa9,?a d9v 4)ee-.Llo►"3y< 3 <br /> ❑Public/Colmnercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number/ r❑y Village of _ <br /> iVod It /)/�•� IaTownof Jae.lSSOt� <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' JX New System <br /> y El Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification 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 Expiratiod Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that a I ) <br /> Non-Pressurized In-Gmund ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 im 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 Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sl) System Elevation <br /> 445 a 1 S— 90 0 1 90 a 913- 41 <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks '` y <br /> 0 <br /> o. U U a. <br /> Septic or Holding Tank ADO /bd O <br /> Dosing Chamber �I A(� y/j O� <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I Plumber's Signature [LMP=MPRLSumber Business Phone Number <br /> J�iG/c / a el"5 /� // 1 7is=8G�4v�s-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77G4 h�t 3.s" L✓' S><Yr 4t/1 5�893 <br /> III.County/Department Use Only <br /> Approved ❑ Disapproved Permit FeeDate Issued Issuing Agent Signatur <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEOVE <br /> I <br /> I Attach to complete plans for the system and submit to the Cmtnty only on paper not less than 8 I s 11 ches 2017 <br /> UU <br /> SBD-6393(R0313) I BURNETT COUNTY <br /> ZONING <br /> I <br />