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is gni 1 County <br /> ✓ Industry Services Division a vN r <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P 3� P.O. Box 7162 <br /> 075? 9 <br /> � 1 Madison, WI 53707-7162 /T—� <br /> 17 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis,Adm.Code,submission of this Conn 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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parce ti <br /> Z ,e,f1le Tiw.be�/aloe 07-��l.t-1`41`/ 4 <br /> - L)o 13aoo <br /> Property Owner's Mailing Address Property Location <br /> 014? 7/ 4:fr4Lrl b err ZA64e <br /> Govt.Lot <br /> City,State Zip Code Phone Number p y,, y., Section Jm. <br /> DAy P K N Sit/ ��d �d` y8�` /!i BJ� circle one <br /> T y� N; R�E08 <br /> II.Type of Building(check all that apply) 11 Lot# <br /> [9Ior2 Family Dwelling—Number ofBedrooms U\ Subdivision Name <br /> Block# 5`< s� <br /> ElPublic/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CStvl Number ❑ Village of <br /> Town of <br /> 1TI.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System JXReplaccurent System ❑Treannent/I-[olding 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 /> g 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 3 o a . 7 y,1 g 4..?.t 9 ti. v <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o $ o <br /> New Tanks Existing Tank o v 2 y to �2 <br /> Septic or Holding Tank Soo GO0 / S��A (,v x <br /> g Dosin Chamerb C <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWI'S shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign re MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 01 7 7l.O lye- y ZJ- tyC6fxe/ 1A S /�9 3 <br /> VIlI.Coun /De artment Use Only <br /> Approved ❑ Disapproved I emit Pee O Date Issued Issuing Agent Signatu <br /> ❑ Owner Given Reason for Denial $' 7� ��—1 <br /> 17 "a44i <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEIVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than E 2 s W <br /> m:11111111MAZeL <br /> BURNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />