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Coun <br /> t Safety and Buildings Division <br /> 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> \$P •' Madison,WI 53707-7162 Q-7) <br /> Transaction Number <br /> Sanitary Permit Application State Trasad 7D <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. Notes Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Ser-vies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 I m,Stats. \\ e <br /> L Application Information-Please Print All Information <br /> L Ch <br /> Property Owner's Name Parcel# <br /> Ler to 0-7-01q-3-38-t�3�-s- <br /> fJ) % tr " <br /> Property Ow er's Mailing Address Property Location <br /> ?� ? 0 3 Govt.Lot 31 <br /> City, late Zip Code Phone Number y,, y., Section <br /> O M B A, N To C( -�— c e one) <br /> T_3N; REorf` <br /> IL Type of Building(check all that apply) Lot# <br /> or2FamilyDwelling—Number ofBedrooms Subdivision Name <br /> Block# <br /> ❑ Public/Commercial—DescrlbeUse <br /> ❑City of <br /> ❑State Owned—Describe Use <br /> r <br /> Number LlVillage of <br /> Jownof LCi I( re, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. $11liewS stem <br /> y ❑ Replacement System ❑ TreatmenUHolding Tank Replacement Only Ll Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com ponent/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In Ground ❑ At-Grade VI-Mound>24 in of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) [Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Applic tion Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> IS"o 15 /S o 100 <br /> VI.Tank Info Capacity in Total #of Manufacturer q <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks & a <br /> o. v rn c7 a <br /> Septic or Holding Tank �Q <br /> Dosing Chamber ::X�b <br /> VII.Responsibility Statement- I,the undersigned,assume ponsibili forlastallation of the POWTO&AWwn on the attached plans. <br /> Plumber's Name(Print) Plumber's Si t / RS Number Business Phone Number <br /> IJR�► ���at god �l5` yl� �,<</�1.. <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 90,k G7 00A/e(L b< <br /> VIII.CountvIDepartment Use Only <br /> Approved 1 ❑ Disapproved ermit Fee Datelssued Issuing AgentSignatur <br /> L-1Owner Given Reason for Denial P <br /> 37S -�y- <br /> $ )x/I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than a 12 x 11 inches in s <br /> JUL 13 2016 <br /> SBD-6398(IL 11/11) n <br /> BURNETT COUNTY <br /> ZONING <br />