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County <br /> r/�' ,+ Industry Services Division j�krN t �f <br /> itS Xy 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P � P.O. Box 7162 5g <br /> �A �� �_� Madison, WI 53707-7162 <br /> Sanitary Perrnit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Rq 83-�> <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. 15.0 l)(m),Slats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> p7.04j-J-30- /J T3-J Oa 0'0 <br /> .Jame J aM01�4 _ 011000 <br /> Property Owner's Mailing Address Property Location <br /> ) :�_7AY 6D ?V Govt.Lot <br /> City,State Zip Code Phone Number A/W /., S'(IV /., Section 33 <br /> G -/S6 ,5�5/8 (circle one) <br /> II.Type of Building(check all that apply) J Lot# T 3 8 N; R /8 E or&V <br /> 1 or 2 Family Dwelling-Number of Bedrooms '^ Suhdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use 7 �7, <br /> CSNI Number ❑ Village of L} Town of b✓&4Vf !Z t 61<.- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System WReplacement System ❑Treatmerun lolding Tank Replacement Only ❑ Other Ntodilicalion 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 Sys tem/Com onent/Device: (Check all that apply) <br /> ❑ Non.Pressurized in-Ground ❑ Pressurized In-Ground ❑ At-Gmdc Mound>24 in.of suitable soil H 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(go) Design Soil Application Rate(gpdso Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 7 0 . 9 ,?C0 3e <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u o <br /> New Tanks Existing Tanks <br /> q <br /> Septicor Holding Tank elo CtyO <br /> Dosing Chamber C-O'b O.j O0 <br /> VI 1.Responsibility StateJment- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MPiMPRS Number Business Phone Number <br /> R/GlG 17e k" f s�rl-ffiS J 7�.5%�G6—�l�•f 7 <br /> Plurmber's Address(Street,City,State,Zip Code) <br /> d 77jya ,ems <br /> III.Coun /De artment Use Only <br /> Approved ❑ Disapproved Perm2it-F7ee DQate Issued Issuing Agent Signa re <br /> ❑ Owner Given Reaso¢ <br /> [X.Conditions of Approval/Reasons for Disapproval <br /> nDECEPVEnn <br /> Attach to complete plans for the system nod submit to the County only on paper not less than 31 t ches in size <br /> AUG 0 1 1017 <br /> SBD-6398(R0313) UUBURNETT COUNTY <br /> ZONING <br />