Laserfiche WebLink
yz� County` .• ;„4 Industry Services Division �3V'r vt ,°7y <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison, WI 53707-7162 ���r2�r 2z� <br /> - a -1 1 <br /> Sanitary Permit Application 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 Servies. Personal information you provide maybe used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> o7 o�t8�� /0—/N <br /> �" le SfiGv,ar o37/bv <br /> Property Owner's Ivfailing Address Property Location <br /> 3s9 RAt-t h-p- 1_), Govt.Lot <br /> City,State Zip Code Phone Number / '/a, Section /.3 <br /> s o d N ✓ LL� �( gd — 17 (circle one) <br /> I1.Type of Building(check all that apply) Lot# T N; R_ E or&V <br /> ,W I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number Y 79 7 ❑ Village of <br /> �/ d? ZTOwn of fGJ'7Y <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑ New System �teplacement System p y y ( p <br /> B. El Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> lV..T"'e,of POVM.5 stem/Con onent/Device: (Check all that apply) <br /> Non Pressurzed In-Ground El Pressurized In-Ground ❑ At Grade ❑ Nlound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Fi ldm=Tank ❑Other Dispersal Component(explain) El Pretreatment,Device(explain) <br /> V�;D s ersaI/Treatment Area information: <br /> Desigu�Iow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> v <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o v a m <br /> c U cn v, w C7 a <br /> Septic or Holding Tank <br /> Dosing Chamber_ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7741 o few' 3tr /ti-e�f f r.- L✓1 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee dp DD(at Issued Issuing Age t Signatur <br /> ❑ Owner Given Reason for Denial $ 5 I�'+V <br /> IY.Conditions of ApQroval/Rea ons for Disapproval <br /> �f� 4�5 <br /> rn4sf' be- J- SEA' 1�2.22 <br /> Mai �Je. 3�+- o� e,�c, � �YPA ►;A �: tip if <br /> � lad <br /> Attach to complete glans for the system and submit to the Co Daly on paper not less than 8 t/?s 1 inches in size Burnett County <br /> Land Services Department <br /> SBD-6398 (R0313) <br />