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' /,r5'ailti`► County ,p <br /> { ;,. • Safety and Buildings Division Y66oi�1e <br /> •! j `L" 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> :s...- Spf I l Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit [1-l�y Tevit'u., <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(I)(m),Stats. .2 <br /> ` r '''' 1 <br /> I. Application Information-Please Print All Information l wG'7 fri <br /> ed <br /> Property Owner's Name Parcel# 07-D7,8-z-ifoitha5'JS DS•W3-411: O <br /> 6k '4a'' (CO 3.5)7( <br /> Property Owner s Mailing Address Property Location <br /> /04( Cedc Lw Govt.Lot 3 <br /> City,State Zip Code Phone Number /�� �/ y. ''/., Section ZS <br /> ifeW151 LN i SyDZI �jl5)TZZ—�yh� % (jircleonfJ") <br /> T D N; R e° <br /> II.Type of Building(check all that apply) Lot# <br /> g1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> 13loek# <br /> ❑Public/Commercial-Describe Use 0 City of <br /> CSM Number 38/097 0 Village of <br /> ❑State Owned-Describe Use <br /> Town of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> List Previous Permit Number and Date Issued <br /> 0 Change 0 Permit Renewal ❑Permit Revision of Plumber 0 Permit Transfer to New <br /> Before Expiration Owner — <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> irNon-Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/freatment Area Information: <br /> Design Flow(gpd) Design S,il�plication Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) SystemElevation <br /> gl <br /> VI,Tank Info Capacity in Total al #of Manufacturer y S <br /> Gallons Gallons Units u u H N <br /> New Tanks Existing Tanks ` c v 2 a <br /> r au . H v> LT.O a <br /> Septic or Holding Tank /) 1 loco I t, r1 V�,/.r+ <br /> Dosing Chamber VW�,/� <br /> VI1.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu 's Name(Prin Plum Signature MP/MPRS Number Business Phone Number <br /> K loll tr r�-C'�i ff 196 r -ga-gam <br /> Plumber's Address(Street,City,State,Zip C <br /> VV, II//I.County/Department Use Only _ <br /> la'Approved ❑ Disapproved Permit Fee Date Issued Issuing A gnature <br /> 0 Owner Given Reason for Denial 3,J w J�12... / <br /> IX.Conditions of Approval/Reasons for Disapproval7 ,,,, , <br /> JUL — 5 2012 J <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 Me e / <br /> BURNETr COUNTY <br /> SBD-6398(R. 1 I/11) ZONING <br />