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r'+g. ii14--t County j5 <br /> �' ' ,. Industry Se&ices Division OtAret <br /> rr n S 4'I 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 5.-1tJ- 1`6„j la <br /> i ,`fi Madison,WI 53707-7162 <br /> .;f;,. Ci as 3 1 3 C 7 <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 /V '/ <br /> is required prior to obtaining 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 Servies. Personal infonnation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. /M_(0 N'2 ‘Rot <br /> I. Application Information-Please Print Allinformation <br /> Property Owner's Name Parcel# IS 07-,5'ps 00-0 <br /> L otw-.t-38- <br /> L, &Gill /Yltk✓Let.s/NlA� 07 ol1360- o21 44 60 <br /> Property ' �' <br /> Owner's Mailing Address Property Location 14143t1155 <br /> er <br /> o•-44 /38/-t- �'1' Govt.Lot 3 <br /> City,State Zip Code Phone Number 'A, 'A, Section 7 <br /> AMe.-7 4y_. 52,00 i T 38 N; R /�clEor�J <br /> II.Type of building(check all that apply) ) Lot t '` <br /> I or 2 Family Dwelling-Number of Bedrooms d I. Subdivision Name <br /> Block# 1 <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use C1S/Ni Number Q 0 Village of <br /> Y lta . 1 1 Q7 z J �Townof La'Fo/teAI c <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) v <br /> A. New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 0 Change ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision of Plumber <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> PNon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 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(st) System Elevation <br /> yG o , ,y'' 6 v0 Goo 93, 5- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> y <br /> Gallons Gallons Units ., o <br /> New Tanks ' Existing Tanks V " " H <br /> c.U .. ti • tZ.Q 0. <br /> Septic or Holding Tank /O sa AV-0 / _Ty /I,•t�✓4.r<-„, X <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print)' Plumber's Signature MP/MPRS Number Business Phone Number <br /> /�t'f Tle /bin$ /2e i/z-J2 )).5-8-i-f 7dS-'£l-e-f/,f'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> \ <br /> al7700 ,... y 35- 14'-e65 fern 14'I St? A <br /> VIII.Count�/Departmenf Use Only I <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved 0 Disapproved $ `'� a0 Q' <br /> 0 Owner Given Reason for Denial 3 / 7 010 - �V , <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APPROVED <br /> Jill <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 s 11 in`es in ze <br /> BURNETT COUNTY <br /> ZONING <br /> SBD-6398(R0313) <br />