Laserfiche WebLink
County <br /> ? Safety and Buildings Division U/�y <br /> 201 W.Whin <br /> �5 g Sanitary Permit Number(to be filled in by Co.) <br /> ;• PWashington Ave..P.O.Box 7162 <br /> S ,i Madison,Wl 53707-7162 t aZj7/� <br /> yJOc� <br /> Sanitary Permit Application State Transaction Number CA <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 information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15. 1)(m),Stats. d, <br /> L Application Information-Please Print AR Information Ale? t`v�/1 <br /> Property Owner's Name Parcel# r <br /> u n/ ,2-10-17- <br /> PropertyOwner's Mailing Address - Property Location <br /> �5_�' ' 740 Govt.Lot <br /> City,State Zi Code Phone Number <br /> /�,/,// P �' S Section 17 <br /> v4r�eV� /N• 7-bO N; R .SS►➢cIEonq�-� <br /> T <br /> II.Type of Building(thee all that apply) Lot# — (� cCV <br /> Jor 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ATownof_ UMb <br /> I11.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System 4rReplacement 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 liaoound<24 in_of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Ar�;uired(sf) Dispersal posed(sf) System Elevation <br /> V L Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanl-sExisting Tanin 2 <br /> ks w c v <br /> ri C% in N iDs. U a <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VTI.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWYS shown on the attached plans. <br /> Plum s Name(Print) j Plum ignamr MPtMPRS Number Business Phone Number <br /> oIi5 D� n em 1/ SS�gS ?�5~56r; -02_0Z. <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> VII[.County/Department Use Only <br /> Approved ❑Disapproved Permit`F]eeq Dnte Issued Issuing Agent Signatu <br /> ❑Owner Given Reason for Denial S I II//�/� <br /> I%.Conditions of Approval/Reasons for Disapproval <br /> nDECEIVErn,: <br /> Attach to complete plans for the system and submit to the County only on papa not less than a t/2 x 1 sire <br /> c 1 <br /> JUL 1 2016 LLJ <br /> SBD-6398(R. 11/11) BURNETf COUNTY <br /> ZONING <br />