Laserfiche WebLink
CouR <br /> „4 Industry Services Division i r^ry-!7� <br /> ,421 .yJ ;,,j.: . .ier 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 ` <br /> Madison, WI 53707-7162 J� �2 1�35 (p <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,subutission of this form to the appropriate governmental unit <br /> is:required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS are submitted to Pro ct Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary 301 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. hSCtt wr <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# cal <br /> r°�8-a-y <br /> Property Owner's Mailing Address Property Location 7?3 <br /> 1 3 S'3 W, Govt.Lot 3 <br /> City,State Zip Code Phone Number y,, /4, Section <br /> U C h-e,3 f_P v P-) ry ,�_> V7 , y0 trcle one) <br /> 11.Type of Building(check all that apply) Lot# T N; R J 7 E or�O <br /> �rl or Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Cotnmercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> WTown of -fG d <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ANew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other lv[oditication to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision ElChange of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T"e.of POWTS.S stem/Con onent/Device: (Check all that apply) <br /> Non P es rized In-Ground ❑ Pressurized[a-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil. <br /> ❑ I{gldm>Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Ds ersal/Treatment Area Information: <br /> DesignF,(gpd) Design Soil Application Rate(g�pdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> 30() .S 60a 9 3. F <br /> VI.'Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a U <br /> New Tanks Existing Tanks o <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility.Statement- I,the undersigned,assume responsibility for installation of the PO'Y'VTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sigma ref/ MP/MPRS Number Business Phone Number <br /> 171�1C Ad 1Gins <br /> Plumber's Address(Street,City,State,Zip Code) i <br /> 7 7e�0 SY 6r53 <br /> VIII.County/De artment Use Only <br /> Permit Fe Date Issued Isjignapproved ❑ Disapproved ''nn �j❑ Owner Given Reason for Denial y5 013I� - <br /> IX..Coonnditions of A provallfRe�sons f r Disapproval� � -7 See Revision SAP 2 8 2022 <br /> �a� <br /> Attacb to complete plans for the system and submit to the County only on paper not less than 8 t/?.1 11 inch <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(110313) <br />