Laserfiche WebLink
4�w'�. Industry Services Division County n -/1 <br /> 0 ;c,tz\ 1400 E Washington Ave oi,'d <br /> `:. Sp " P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> .t., S ;;r,' Madison,WI53707 7162 C' J-2,3 --L0- to5(. <br /> Sanitary Permit Application I 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(I)(m),Stets. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> (q(fy Ark o7-0/7-740-6-��-S"/6-'m-ouL� <br /> Property Owner's Mailing Address /� f',/-� Property Location p 1 L, <br /> 78 JR)/I / :0 N Govt.Lot OJ T'7 <br /> City,State! t ZipZi Code Phone Number fv, %,, Section f/ <br /> Ogi,ibui}/ Li), 83e leE ne <br /> T. 00 N; REo o V� <br /> II.Type of Bulldin (check all that apply) Lot# <br /> Y I or 2 Family Dwelling—Number of Bedrooms z Subdivision Name <br /> Block# 4o7 iVitii 14 Vv <br /> ❑Public/Commercial—Describe Use 0 City of <br /> ❑State Owned—Describe Use GSM Number 0 Village of T <br /> Ig Town of J 4L IJ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System 5'Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. CIPermit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 51 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Disp I Area Proposed(sf) Syst m Elevation <br /> ri �'/] _ 1/7 z 7 i.7 '9/7 <br /> VI.Tank Info ` Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks t g• It ;, 1 <br /> a.V VI TA to IZ t7 a. <br /> Septic or Holding Tank Ba) Qin J / /�y'� f�/ iA) `! <br /> Dosing Chamber C 7� <br /> VII.Responsibility Statement—I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plut cr's Name(Print) i Plum ig,nacttrc MP/MPRS Number Business Phone Number <br /> ,.cam M4f( i 7-- 8 /952/ 7/T-Tg-62.oz <br /> Plumber's Address(Street,City,State,Zip Code) <br /> t8l %�74 Al Ile 4/ Lie r L"1- 5i14809, <br /> VIII.County/Department Use Only <br /> 0 Approved 0 Disapproved Permit Fee Date Issued ing eat S . <br /> I5❑Owner Given Reason for Denial <br /> 1�ql � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> .ee-E- qt1 Se-- k.cls - 5-?. .-k re :ne."0), 2.���c <br /> Lcr s -fp be co nb:44 ,. 1c - I I .5e�OC-C (co rle4 .he ✓tte4 ✓r'�q Ce rMieA Sit �4�IAttach to complete plans for the system and submit to the County only on paper not less than 8 WI x 11 inc1 -FC -FINE0 <br /> Atte J U N Z 8 2u23 <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) <br />