Laserfiche WebLink
= y Industry Services Division County <br /> 1400 E Washington Ave <br /> P.O.Box 7162 Sanitary Pemdt Nmber(to be filled in by Co.) <br /> Madison,WI53707 7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38311(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application fomms for statewwned POWTS are submitted to Projat AA r=(if different titan mailing address) <br /> the Department of Safety and Professional Sevices.Personal ftdostnation you provide may be used for secondary tF LI/purposes in accordsace with the Privy LAW s.15.04 2 Stars <br /> L Application Information-Please Print All%formation q <br /> Property Owner's Name PMd# <br /> Property Owner's Mailing Addressa r / property Location <br /> Gaut.Lot CJ # �o 2 <br /> City,State 4U,( <br /> Zip CodePhoneNumber V, Y; Sectio,IAI 551 Z�J60 <br /> H.Type of Bullding(check all that apply) Lot# <br /> T JIO N. R <br /> Qr l or 2 Family Dwelling-Number of Bedrooms -z— Subdivision Name <br /> BlorktF <br /> 0 Public/Cornmermal-Describe Use City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> V-77 ?TO Town of (4-ekm r-) <br /> III.Type of Permit: (Check only one box online A. Complete line B If appUrable) <br /> A. M New System ❑Replacement System ❑T=ment/Holding Tank Replacement Only Other Modification to ExistingSystern(explain) <br /> B• ❑Permit Renewal Q Permit R nision ❑Change of Plumber Q Permit Ttamfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV,Type of POWTS S tem/Cora onentM*vlce: Check all that apply) <br /> Is Non-PrMWzed In-Ground ❑Pressurized In-Ground Q At-Grade Q Mound 124 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) Q Pre4ratment Daviee(ecpiain) <br /> V.Dispersal/Treatment Area Wormatlion: <br /> Design Flow(gpd) Design 1 Application Ri Area RequiredEl <br /> (sf) Dispersal Area Proposed(sf) System evation <br /> 3oa ate(gpdst) Dil yz� 1W �z <br /> VI.Tank Info Capacity in Total #of Mantr acturer d <br /> Geri= Gallons Units <br /> New Tanks Existing Tanks +9 ` At $ g A <br /> U iA oil ii t7 � <br /> Septic or Holding Tank <br /> Domg0tamber �V <br /> VII.Responsibility Statement I,the under SlSned,assume )city for a of the POVV'!S shown oa the attached plans. <br /> P u 's Na <br /> me Pltrrttbcr'a S MP,'MPRS Ntutmber Bnaimess Phone Ntrmbcr <br /> �� �ol�5 7/5-�,f�-dZD� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �691 40F;4W I A- Wd <br /> VIIL Coun evartment Use Only <br /> WApproved ❑Disapproved Permit Fee 5;0 Date liouu�ed/ ' <br /> Owner Given Reason for Denial 1 "37 <br /> 5� '.Jv I(�� . <br /> IX.Con tions ApproyWIRWons for Dhgprevai <br /> 5n'ls -6 be F✓6rW/ 6 �' cr S 'Ira�`r `,ip.,. �yq €e r11 <br /> Attach tosompleteplaus for the system and submlttotheCatWa*onpaprnatimthaasmzn laft Burnett County <br /> 7 Land Services Department <br /> SBD-6398(R 08/14) <br />