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County <br /> Industry Services Division Oc.t^11 e <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> Pi P.O. Box 7162 <br /> "J 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 fors 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),Stats. <br /> L Application Information-Please Print All Information o 7 <br /> Property Owner's Name Parcel# <br /> %� - .Sc�tu (tom o�-of9-d-38-/s e&S-'/S_6 4 <br /> J3re <br /> - 0/0000 <br /> Property Owner's Mailing Address Property Location <br /> /A `l`78' 193.-01 4py /l/N/ Govt.Lot <br /> City,State Zip Code Phone Number y, Section <br /> ��(0 ��fvtir `jt/t/ Sl 330 Gsi-aY&- r9sr TR 1�0neWleou <br /> II.Type of Building(check all that apply) Lot# N <br /> 111 or2Family Dwelling-Number ofBedrooms Subdivision Name <br /> Block It �a1 <br /> ElPublic/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> C'SM Number ❑ Village of <br /> XTown of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' X New System y ❑ Replacement 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 ❑ 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(sf) -; Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o v <br /> New Tanks Existing Tanks U y <br /> w u <br /> G v <br /> 0 <br /> c. 0 n y <br /> Septic or Holding Tank I�t`-O Q f'G e [y/eft.� <br /> O J� <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/bIPRS Number Business Phone Number <br /> k, e,/< >4o /e,� s 12e� ddLs-�s 7�r- ffGc_ vis`? <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 0 civ-chs 7e, SY853 <br /> VI I.Countv[Deliartme&Use Only <br /> Perit Fee Date Issued Issu g Agent Si atur <br /> Approved ❑ Disapproved $ <br /> ❑ Owner Given Reason for Denial J�7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> VIM <br /> A 0 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IC x l l inches i 4 <br /> BURNETT COUNTY <br /> SBD-6393(110313) ZONIN-G <br />