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1nZ' �` - County / <br /> Safety and Buildings Division <br /> it D '1 201 W.Washington Ave..P.O.Box 7162 Sanitary Perrot Number(to be filled in by Co.) <br /> S P g Madison,WI 53707-7162 <br /> i <br /> S ".f <br /> Sanitary Permit Application SatcTmnsactionNtmnber <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 fortes for sane-owned POWTS are submitted to Project Address(if different data 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.1i.04(Ill m).Stats. ZQTt0 / <br /> 1. Application Information-Plense Print All Information (r`I <br /> Property Owuer's Name Parcel# <br /> Dower 61 11uj <br /> Property Owner's Mailing Address Property Location <br /> 5*6) r Gavt.Lot 6 <br /> City,State A�ga Zip Code Phone Number y,, /,, Section <br /> AAJAJ �,"�' circiconc <br /> 11.Type of Building(check all that apply) Lot# T Q_N; R�E or�+ <br /> I91 or 2 Family Dwelling-Number of Bedrooms 6- 2 8 Subdivision Name <br /> Block# G k 540ft <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number Q Village of <br /> f Tovmof 4c0/74- <br /> Ill.Type of Permit: (Check only one box on Hae A. Complete line B If applicable) <br /> A' L8 New S stem ❑Replacement System <br /> y ep ys ❑TreattmenUHoltiing Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. Q Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to Ne W List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of PONVTS System/Component/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade Q Mound>24 in.of suitable soil ❑Mound a 24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersol/Treatment Area Information: <br /> Design Flow(,-pit) I Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 o'� o <br /> New Tanks Existing Tanks u c "� <br /> c.U iii rn i:.O a <br /> Septic or Holding Tank / <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation or the POWTS shown on the attached plans. <br /> Plum s Name(Print) f/ PI Signature MPtMPRS Number Business Phone Number <br /> Plumber's Address(Stmt{City,State,Zip Code) <br /> /� <br /> T440/,tcvf/1C✓ `/y av/oS + tr�t SZ{�g <br /> VIIL County/Department Use Only <br /> Approved ❑Disapproved Permit Pee Date Issued Issuing Agent Sigma <br /> ❑Owner Given Reason for Denial S 3 7 S 7-/7 ' 7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 11 ECEIVE nn <br /> Attach to complete pLns ror the srstern and submit to the County onla-on Paper not lea than 912 z {neflel in siyt t 13 <br /> 2 <br /> 017 <br /> BURNETT COUNTY <br /> SBD 6398(R, I I/(1) ZONING <br />