Laserfiche WebLink
County <br /> r N',_ Industry Services Division 131A V1-P_7 _ <br /> tf' y"11 P 1400 E Washington Ave Sanita Permit Number to be tilled in-by Co.) <br /> �) sio See Revi <br /> . �•, P.O. Box 7162 <br /> Madison, WI 53707-7162 ��/ Q� <br /> 'n b CCJJ <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 goverainental unit <br /> is,required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO4VTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal infonnation you provide maybe used for secondary Z 32 S <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. �,'le /fin y ! /?Gl <br /> I. Application 1hformation—Please Print All Information :353�2 <br /> Property Owner's Name Parcel# as--S-/J— <br /> o7-vd8�d-yo'/Y- <br /> �� <br /> PropertyllOwner's Mailing Address Property Location <br /> 3J�0 l hot �v{ S Govt.Lot <br /> City,State Zip Code Phone Number y, �/4, Section <br /> �'✓� �S M A/ 5-r4 06 y0 circle one <br /> 11.Type of Building(check all that apply) Lot# T N; R /7 E or / <br /> KI I or2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Cotnmercial-Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSNi Number L�9 dS' p Village of <br /> V 4•.7 R1 Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ty New System ❑Replacement Systern ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. Q Permit Peaewal ❑Pen-nit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..TTy"p*e.ofPOW S,S stem/Com onent/➢evice: (Check all that a I ) <br /> Non;P1egs€rrize In-Ground-Ground ❑Pressurized[n-Ground ElAt-Grade ElMound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ns <br /> ❑ €i lthk ❑Other Dispersal Component(explain) El Pretreatment Device(explain) <br /> U D s'er aUTreatment Area Information: s <br /> Design"Ftow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) Syst%Elevlou <br /> VI.'Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons UnitsNew Tanks ExistingTanks oUSeptic or HoldngTank /oLQ /Ofi� SNrt 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 /> a_776� s-7�k' 5 I c?q3 <br /> ViiI.Coun /'De artment Use Only <br /> Approved El Disapproved Permit Fee Date Issued Issuing Agent Signature _ <br /> ❑Owner Given Reason for Denial ��15 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ► L C� M L <br /> lblloW Wj aJ S-u.4 re t AKAi,4. 5 <br /> ��1 2 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x i t i es ize <br /> Burnett County <br /> Land Services Department <br />