Laserfiche WebLink
Industry Services Division County J�. <br /> z'� yt; 1400 E Washington Ave j; t l//Vrig`' <br /> P.O.Box 7162 - �iinitary Permit Number to be filled in by Co. <br /> 1.y S Madison,WI 53707 7162 �]14 <br /> NT <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 governmental unit <br /> is required prior to obna,,,it g 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),Stats. u /]/ <br /> I. A �r 7 Application Information-Please Print All Information 1 KA/ <br /> Property Owner's Name // Parcel# <br /> �4 ,-et,Jei*e"�l -o2�2-ya�=2y-3 oz-cam-o <br /> Property Owner's Mailing Address Property Location <br /> 2 !I 4,GOr?k, V� Govt.Lot TQ X t 58 g <br /> City,State / Zip Code Phone Number , Z�w/i_�/,, Section <br /> rLV I/ l� Cj�I D� �/n (circle o <br /> II.Type of Building(check all that apply) Lot# T u N; It, E <br /> l or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> �, <br /> Block R <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> /.5717Aq A 37 §rTo",i of SRC rJ <br /> I11.Type of Permit: (Check only one box on line A. Complete line B if applicable) 7 <br /> A* ❑New System Replacement System g Replacement y Existing y ) <br /> ep ys ❑Treatment/Holding Tank R lacement Only Other Modification to Exisi 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 Owner r j <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Nr Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.ofsaitab)e soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3OU . ;I,- hod biz <br /> VI.Tank Info Capacity in Total =of Manufacturer <br /> Gallons Gallons Units ' o g <br /> New Tanks Existing Tanks aUi `z y a <br /> Sepik or Holding Tank e)6 86 0 /� 4 w <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plun cr's Name(Print) Plumber' r tarc MP/MPRS Number Business Phone Number <br /> Plumber's Address(Stt ee `t,City,State,Zip Code) f <br /> 4, Ah <br /> & i /}vm n/ C/e /ew (Aje eziAr vi 51707 <br /> VIII.CountylDepartinent Use Only <br /> ,�.Approved ❑Disapproved Permit Fel�e /Date ssu <br /> f Ie(� Issuing Agent Sigaatnre <br /> ❑Owner Given Reason for Denial S ��v <br /> IX,Conditions of Approval/Reasons for Disapproval _ <br /> ��low au ca tn+� alj s4cc->tt I <br /> Attach to complete plans for the system and submit to the County only on paper not less thou girl z t t in lift t2 <br /> 0 C T 2 1 2024 <br /> Burnett County <br /> SBD-6398(IL 08/14) Land Services Department <br />