Laserfiche WebLink
'.� Industry Services Division County n <br /> 1400 E Washington Ave <br /> S ' P.O.Box 7162 <br /> Sanitary Permit Number(to be filled in by Co.) <br /> l%1 - Madison,WI 53707 7162 <br /> Sanitary Permit Application State Transaction NumberIn 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),Slats. <br /> I. Application Information-Please Print All Information / (� <br /> Property Owne S Name Parcel## <br /> KV d- X /`5 Cr <br /> INSf O�oIZ-L�a- --/�'S'os=�9'onoo0 <br /> Property Owner's Mailing Address Property Location <br /> Z,� 8 1 T oe- GovL Lot L <br /> City,State %, <br /> Zip Code Phone Number 4, , Section <br /> �^ �a <br /> oe?37I Z t/�� rcle one <br /> II.Type of Building(check all that apply) Lot# <br /> T -0 N, R E o <br /> JI or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSIVi Number ❑Village of <br /> Town of -J06+k7o <br /> Ill.Type of Permit: (Check only one box on tine A. Complete line B if applicable) <br /> A. lL}New System ❑ Replacement System <br /> Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B- ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Otimer 19 7.a <br /> IV.Type of POWTS System/Component/Device: (Check all that a 1 <br /> 11 Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment De\rice(explain) <br /> V.Dis ersaltTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(g Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> q5b pdsf) 6y9 6y8 79f`i' Q�'2 <br /> VI.Tank Info Capacity in Total R of Manufacturer <br /> Gallons Gallons Units <br /> 0 <br /> New Tanks Existing Tanks <br /> a U v yr iz a <br /> Septic or Holding Tani: <br /> Dosing Chamber /QO <br /> Vii.Responsibility Statement-L the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) Plumb Signature: MP/MPRS Number Business Phonc Number <br /> Plumhpr's Address(Street,City,State,Zip Code) <br /> l AVOIAW t l� Wl (leb51-t- �l� 5 529 <br /> VIII.Coun /De artment Use Only <br /> P'Approvcd ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ ��. ' 3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> EMAY77n, <br /> Attach to complete plans for the system and submit to the Counh only on paper not less than 81/2 s I I <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08114) y 25` # 125 <br />