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Cofflmeme.WLgov Safety and Buildings Division CountyM 201 W.Washington Ave.,P.O.Box 7162 <br /> Isco■ ■sin <br /> Madison,WI 53707-7162 Sanila{y ermit Number(to be filled in by Co.) <br /> roar <br /> C Dwwbnwg of Continuation 060 <br /> Sanitary Permit Application State Transactic,Number <br /> In accordance with s.Comm 83.21(2),W is.Adm.Code,submission of this form to the appopriate governmental �y <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different thanmaiting address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary r� t <br /> purposes in accordance with the Privacy Law,s. 15. 1 m Slats. /, w <br /> L Application Information-Please Print All Information a <br /> Property Owner's Name Parcel# <br /> I d—Uh f 03a- 343— <br /> Properrtty D er's Mailing A /� Property Locati n <br /> 11 -7 GLuLe, Govt.Lo[ <br /> City,Statey. n Zip Code Phone Number / / Il�f 1,) Y., /., Section <br /> WC /C <br /> . ) 1`QU qq - J ' 105 o (circle one) <br /> II,/�ype of Building(e eek all that apply) Lot# T�_N; R�._ <br /> 17 1 or 2 Family Dwelling-Number of Bedrooms 3 SubdivisionNam <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use \ ' <br /> CSM Number Village of lo <br /> V+ I(0 tEl Town of <br /> III.Type of Permit: (Cheek only one box on fine A. Complete fine B if applicable) <br /> A. y.New System ❑Replacement System ❑To niounNHoldiog Tank Replacement Only ❑Other Modi cation to Existing System(explain) <br /> B. ❑Permit Renewal ❑Pemrit Revision ❑Change of Plumber ❑Permit Transfer to New List Premium Pi imit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com nent/Deviee: Cheek all that apply) <br /> Noo-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<2, in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersadirfrentment Area Information: <br /> Design Flow(go) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) /Dispersal Area PProposeed(sf) System Elevation <br /> k J 65br ,q `[U)c Rat 3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tasks Existing Talcs <br /> Sgxic m Holding Task I CM <br /> lo� 1 <br /> Dosing Chamber l l <br /> VII.Responsibility Statement-L the mndeesiped,aasmme responsibility for installation of the POWTS shown an the atts Aed plans. <br /> Plumber's Name(Print) I Plumber's Siganue MP/MPRS Number Business Phone Number <br /> well da(o 7 7/5--&%-J43'/ <br /> Plum 's Address(Street,City,State,Zip Code) <br /> l S0'�cw�, ST ciep olc FJjQ0 wl- SY OW <br /> VIII.Como Department Use Oa <br /> Appmved ❑Disapproved Pemrit Fee Date Issued Issuing Signature <br /> $ r <br /> ❑Owner Given Reason for Denial 07 <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> DQ <br /> 01 <br /> Araeh to eonsphse plain for the rystea and mbmr to t4 County osb on paper not len a in x 11 fu`q /tfmll <br /> SBD-6399(R.01/07)Valid thin 01/09 BURNETT COUNTY <br /> ZONING <br />