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County <br /> � �. y Industry Services Division j3c.v» j <br /> ,S7;: 0 1400 E Washington Ave Sanitary Permit Number(to he filled in by Co.) <br /> '° Sps rI P.O. Box 7162d��17 <br /> ; ' Madison,WI 53707-7162 D s� <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 govetmnental 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 1 <br /> purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats. 7 <br /> I. Application Information—Please Print All Information l o6-e✓7 -r K <br /> Property <br /> Owner's Name Parcel# NO _ty <br /> (C k H(Q ✓a �t a, ! 4 7,O.s- - <br /> dos at b ovo <br /> Property Owner's Mailing Address Property Location <br /> Ile 7 %6/n is e Govt.Lot .!r- <br /> City,State <br /> Zip Code Phone Number '/,, Section Of <br /> /v(eod r"O�'1/�G GIIS ,s-y 7rt (circle one) <br /> Il.Type of Building(check all that apply) Lot# T �/O N; R /y L'or�S <br /> PP Y) g <br /> 1 or 2 Family Dwelling—Number of Bedrooms dr Subdivision Name <br /> Block# <br /> ❑Public/Commercial--Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Town of fG• — <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. W Y P Y I P Y g Sy (explain) <br /> New S stem ❑ Replacement System ❑Treatment Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision El Change of Plumber El Permit Transfer to New <br /> List Previous Pennit 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) ❑Pretreaunent 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 /> 3� S` GDO G/7 9a j/ 9se gel- 8 <br /> VI.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units r v o <br /> New Tanks Existing ranks <br /> 0 <br /> a U vi y ti i+- V o_ <br /> Septic or Holding Tank 7.$V <br /> V <br /> Dosing Chamber .4�jU <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature / MP/MPRS Number Business Phone Number <br /> I ac �d 02/c e r f <br /> Plumber's Address(Street,City,State,Zip Code) <br /> V 11L County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> Z D <br /> El {X 'Owner Given Reason for Denial $J 7 . ;7,A%7 <br /> 1 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> EOE6 i <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 iLbdk size <br /> fl <br /> SBD-6398(R0313) JUL 2 2 2016 <br /> BURNETT COUNTY <br /> ZONING <br />