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County <br /> Safety and Buildings Division r d l_ <br /> S ` 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> PS Madison,WI 53707-7162 <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 infbrmation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m).Stats. <br /> I. Application Information—Please Print All Information !J 04�q G <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location <br /> NO FV beet) Fc,�p Govt.Lot <br /> City,State II,, Zip Code Phone Number ?J <br /> Wboetb� fylN 55a1 G 2 S- /oz �� K. Section <br /> / ac'E one <br /> T K� N; R <br /> It.Type of Building(check all that apply) Lot# <br /> ❑ I or 2 Family Dwelling—Number of Bedrooms 2— Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> V 2S P 266 fI�Town of g Lo t <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System gReplacement 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 S stem/Com nent/Device: (Check all that apply) <br /> IgNon-Pressurized In-Ground ❑Pressurized fnllround ❑At-Grade ❑Mound>24 in.orsuitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersai/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Raic(gpds f) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> o� 4015 �'3 ;7- o tWn <br /> Vt.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a d o <br /> New Teats Existing Tanks 2 As 2 V a a <br /> U As rn r2 O n. <br /> Septic or Holding Tank so y <br /> Dosing Chamber <br /> VII.Responsibility Statement—1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plaits. <br /> Plum sNa�Print) Plumber's m� MPtMPRS Number Business Phone Number <br /> oot �E� 857gS ��$�SSG-OzoZ, <br /> Plumber's Address(Street,City,State,Zip Code)) <br /> 2 nzo <br /> VRL CouptL/Department Use Only <br /> Approved ❑Disapproved Permits Fee <br /> Date issued Issuing Agent Signaler <br /> ❑Owner Given Reason for Denial 1 ' 37St <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEWE <br /> Attach to Complete plain far the system and submit to the County only on paper not lea than 812 a]T <br /> Bch ir <br /> BURNETT COUNTY <br /> SBD-6398(IL 11111) ZONING <br />