Laserfiche WebLink
County <br /> Indust Services Division µrn.e 1 <br /> ry <br /> '• 1400E Washin ton Ave <br /> 9 Sanitary Permit Number(to be tilled in by Co.) <br /> ` P.O. Box 7162 r <br /> Madison, WI 53707-7162SAN <br /> CST 5- 13'i <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adrn.Code,submission of this form to the appropriate govermnental unit <br /> is,required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS are submitted to Projzct Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary (10Or <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Slats. <br /> R <br /> I. Application information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Da t, ye wl <br /> Property Owner's Mailing Address Property Location <br /> s• <br /> Govt.Lot <br /> City,State Zip Code Phone Number Y /., Section �r <br /> Z_44,e �a �t'ti✓ /YI/V S-y 3� S circle one) <br /> 11.Type of Building(check all that apply) Lot# T 3 r1 N; R (� E or <br /> I or2 Family Dwelling—Number ofBedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number rl Village of <br /> 0 Town of C 1.1 c o Jr+ <br /> IIl.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' New System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Pen-nit Revision ❑Change of Plumber ❑Pennit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..( 'e.of POWTS,System/Component/Device: (Check all that apply) <br /> R.NOn Pie Zed in-Ground ❑ Pressurized In-Ground ❑ At'Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑H i[dma Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V"Dis ersll/Treatment Area Information: <br /> DesfgnFltiw(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 300 S' (� e (e0U 9 Jr.J <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units oej <br /> New Tanks Existing Tanks o v <br /> Septic or Holding Tank 1C <br /> oGo /�Go / Z"tir ,/fsaria,. <br /> Dosing Chamber <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the PObVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature bIPMI IRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) \ <br /> T 760 r~. Ts' w-cb-s)4a-- w.J <br /> VIII.Coun /De ar ment Use Only <br /> Permit Fez Date Issued s ,A ent S' afore _. <br /> YApproved ❑ Disapproved Q/ue �" <br /> ❑ Owner Given Reason for Denial $ /� vl-)f//3 t`� <br /> IX.Conditions of Approval/Re sons for Disapproval <br /> ✓he.e�d 5 f s is re Ais,i;5 <br /> U U 7 2023 <br /> /1 of _ rhCin.-j i 3 - o� e2 ' c <br /> Burnett Count � <br /> Attach to complete plans for the system and submit to the County only on paper not less 1 93i epdrtment <br /> SBD-6393(R0313) <br />