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County <br /> Industry Services Division 13u r rl ely_ <br /> P 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> p$ P.O. Box <br /> 53707 S/I i 4i o <br /> ;j Madison, WI 53707-7162 "I`T'Tt(� <br /> 11 Sanitary Permit Application State Transaction Number <br /> In accordance with SIPS�83.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fors for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety' and Professional Servies. Personal information you provide may be used for secondary <br /> purposes m accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> L Application Information-Please Print All Information ,So 3 y 13 t1r 4 T! . <br /> Property Owner's Name Parcel 4 <br /> �a itier D7330%d-NI-/r-oy-r /S- <br /> Property Owner's Mailing Address Property Location <br /> l V �VIf h lql/- Govt.Lot <br /> &Y,State Zip lCr �odee I Phone Number y, '/., Section <br /> !J( OO/MY�' ✓"1 o( 4 7/•s- 17P9 �D7 cucleon <br /> 7-/ e <br /> II.Type of Building(check all that apply) Lot# T y N; R E or(�J <br /> ® I or 2 Family Dwell g-Number of Bedrooms a Subdivision Name <br /> Block St <br /> ❑PPublic/Commercial-Describe Use iudst <br /> ❑ City of <br /> ❑State Owned-Describe Use CSNI Number ❑ Village of <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System A Treannent/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> II <br /> B. ❑ Permit Renew2l ❑ Pen-nit Revision El Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issue <br /> Before Expiration Owner -71 <br /> i <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> 29-Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ A[-Grade El Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevation <br /> ,3 O O 1 °!010 (: r,y in <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks 'v u `; i R `� <br /> r~ V a. <br /> Septic or llolding Tank C�r0 roe <br /> O <br /> Dosing Chamber <br /> i <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) X4�4 <br /> MP/MPRS Number Business Phone Number <br /> RI GlG /`f0 lC trt .9 <br /> Plumber's Address(Stye''t,City,State,Zip Code) <br /> VIII.Coun /De artment Use Only <br /> Permit Fee Dale Issued Issuing Agent Si acre <br /> Approved ❑ Dis`pproved L.� <br /> ❑ Owner Given Reason for Denial 7J' / - q- /7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 11 10.01 -e ff-on, ECENE <br /> 0zz. ,� � ou sdowf ; ,�L 3-e <br /> /&V �a APR - 3 2017 <br /> Attach to complete plans for the system and submlt to the County only on paper not less than S in x 11 inch R. <br /> BURNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />