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Industry Services Division County <br /> xi <br /> t a {) 1400 E Washington Ave g6lrUc°-fF <br /> jj P.O.Box 7162 <br /> t� Sam, Pemu't�hber(to be filled in by Co.) <br /> Madison,WI 53707-7162 �9-�71.3(JO <br /> .s <br /> Sanitary Permit Application State Transaction Nnmber <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 Froject 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(1)m,Slats. � '^ <br /> I. Application Information-Please Print All Information p((J <br /> Property Owner's Name <br /> Parcel# <br /> Property Owner's Mailing Address Property Location <br /> 5 . Govt.Lot J <br /> City,State f A l J Aipcode ;Phio;e Number y, %,, Section oZ� <br /> VV / -��q-7y7q T N; R (circle one,. <br /> II.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms_� d U4 I p} a Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number, 5I p, ;I aU ❑�Village of <br /> V' 7 P18 8�- 99 ( }gp Town of 11AI e lake <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑ Treatment/Holding 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 System/Component/Device: Check all that apply) <br /> ❑ 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 ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> o _ <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank ` Wo + kpei 'ems <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersign sume responsi ''ty for installation of the POWTS wn on the attached plans. <br /> Plumber's Name(Print) um 's Sign' PRS Number Business Phone Number <br /> Zoe, I,l \ewA er o 3Y SG 5 �3 <br /> Plumber's Address(Street,City,State,Zip Code) ( /� <br /> �3 f r 5 �I 1l r7 O <br /> Coun /De artment Use Onl <br /> 07 <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signam <br /> ❑Owner Given Reason for Denial $ `�7, , <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> A/a,q Lo/ z;.vc <br /> p ECEaME <br /> .attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 i c in <br /> BURNETT COUNTY <br /> SBD-6398(R 08/14) ZONING <br />