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10/ 10/ 4014 1J.O1 J`�Juee w. ,.. ••-.� -- <br /> +�PAIITAtgy�,o u v � a R <br /> I i Safety and Buildingscounty <br /> Division c�✓K <br /> H$ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Cb,) <br /> Madison,W153707-7182 W <br /> ,. W <br /> Sanitary Permit Application Stan Transaction Number QD 1� <br /> In accordance with SPS 383.21(2). Wit, Adm. Code.'submission of this form to die appropriate governmental R.IA=d vV <br /> unit is required prior m obtaining a sanitary permit Note: Application farina for sate-owned POWTS are Project Address(if different man mailing Addrgsa) <br /> submitted to the Department of Safety and Professional Strvies. Personal informatinn you provide may he uacd /� <br /> for secondaryourposes In accordanes with die Privacy Law,s. 15.04(l.) ,sun. �72z(.t Tam( Y _ J� <br /> I. Application Information-Pieaae Print All Inrstrimpnoo ! i✓/ U tJt 1� WOan- <br /> Property Owner's Name ° Parcel A OW-40-05-50D /a54cl-M <br /> Jstp.,Fs z 'f as - 07- ozo-z-4o-(&-3)-Sos-oo4-017ae <br /> Property Owner's Ma fling Address Properly Locannn 373J8 37P—5-»-4 R°/ta <br /> S ,U. Boy- 3e 1 Goes. t,pt WEBS{FR IJSSYgg3 <br /> City.Stue Zip Code Phone Numher <br /> w,_ u.sation 31 <br /> ti2u.e.h Sam} 9is- G 6- al (circle one) <br /> 11.Type of Bulidtng(check Ril that apply) l.ne p <br /> T q•O N: R�_P nr W <br /> f&1 or 2 Family Dwelling-Number of bedrooms Subdivision Name <br /> FIOckR C-SOA vl� S <br /> D Pablic/Cmnmercial-Describe Use <br /> ❑ Ciry of <br /> ❑state Owned-Describe we CSM Number ❑ Village of <br /> V1- P 1 64 �Townof QA L-A d0 <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System Replacement Sy.9mm [J Trmonart/ltolding Tank Replacement Only ❑ Other Modification to Exiadng System(cxpinin) <br /> Is. ❑ Permit Renewal ❑ Permit Revision Change of ❑Permit Transfer m New List Previous Permit Number and Date Issued <br /> Rcfrom Pirpirsenn Plumber Owen <br /> IV.Im of]POWTS rem/Com sient/Dorriee: Check all that a l <br /> ❑ Non-Pressurized lit-Ground ❑ Preasurinod In-Ground D At-Grade ❑ Mound > 24 in,of suimble soil ❑ Monad : 24 in.of suitable soil <br /> PCHolding Tank ❑Other Dispersel Component(explain) O Pretreatment Device(cxpinin) <br /> V. pis rsal/Tremment Arca Information: <br /> Design Flow(god) benign Soil Application Rale(gpdsO Dispersal Arm Required(so) Dispersal Arm Proposed(no System Elevation <br /> VI.Tank Info Capacity in Trust s of Marwfachmer <br /> Gallons Gallon Units c E e <br /> New Tnnks Existing Tanks u <br /> ill <br /> %n $ h v. V S <br /> Septic or Nnhllns Tants <br /> Dosing Chamher <br /> VII.Resparloiribility Statement- 1,the undersigned.aaaume responsibility for installation of the POWTS shown on the attached plans. <br /> Pftltnber`s Name(Frio to Plumber's Signa Nrc MP/MPRS Numher Business Phone NumberFF Gw 1--4 .R so31 66 <br /> a if <br /> Plum is Addreas(Street .cot S a.7.ip Cade) <br /> V Coun! /D sent Use ORI <br /> Appttwcd 0 Disapproval Permit <br /> rmitt FFee Date Issued issuing ignature <br /> ❑ Owner Given Rmann for Denial /s�✓ ,2,3 'L <br /> IX.Condltloms of Approval/Reasons for Disapprorai <br /> p EVE <br /> 4na6 to complete pinna for the system and antlimit to the Camay only an paper not tars alum a tri x I Iin alae ' <br /> SBD-6398(R. II/I1) <br /> BURNETT COUNTY <br /> ZONING <br />