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E � <br /> ��;�'� • Safety and Buildings Division County unty t w}1— <br /> w, � 201 W.Washington Ave.,P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> SH�I-I�-IvC� <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 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 information you provide may be used for secondary Q V purposes in accordance with the Privacy Law,s.15.D4(1 m) Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# UA 41 87 <br /> kprt <br /> Property Owner's Mailing Address o IS• -S /5- eon <br /> So oe <br /> Property Location <br /> t'1 !?as' f-Al l7� t`ve Govt.Lot <br /> City,State Zip Code Phone Number /, Y., Section I> <br /> aroakF•e16. CA9 V 5'3 oyS' (circleone) <br /> II.Type of Building(check all that apply) Lot# T L40 N; R 1-7 E or 10 <br /> � 1or2Family Dwelling-Number ofBedrooms3 Subdivision Name T.•..�Sv¢ ZJJq.-,d <br /> �S-(-74 gldtFr+ . VoV ta5er urltt%re. <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 1fF Town of J,4c.k_%.>, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System y p y ❑TreaimenUl folding Tank Replacement Only ❑Other Modification to Existing 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 <br /> IV.Type of POWTS S stem/Com nent/Device: Check all that apply) <br /> 8-Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/freatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> q5-o —0. 1- 75-0 1 -7 7 a' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks w U " u <br /> i <br /> a U 'v, h in i%t7 P, <br /> Septic or Holding Tank <br /> too 6 /000 ( wi tier ]L <br /> Dosing Chamber <br /> VII.Responsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumn , <br /> ber's Name(Print) Plumbe Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P/,00 05- /??9C IC Z W ke <br /> V�IIII.Cour /De rtment Use unly <br /> Ur Approved ❑Disapproved Permit Fee 0 Date Issued issuing Agent S gn <br /> ❑Owner Given Reason for Denial $ TS .'C <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> "Jo rE: h/Ke_ we It oecvpY is bt 4,f 175 f 7i:, Per <br /> Pa+•�rs wrll be etr6rret,Y m� !6z- ?,5 �r lr�a-t- D EC E9ME <br /> /�_ �g Attach tecompteoe plans for the system and submit to the Comity only mpaper not teas than s in x 11 MAY 1 5 V <br /> SBD-6398(R• I1/11) BURNETT COUNTY <br /> ZONING <br />