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County <br /> P U' Industry Services Division r^v 61677/' <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> PS P.O.Box 7162 <br /> +' •. �,.;.;w +r Madison,WI 53707-7162 J <br /> Sanitary Permit Application State Transaction Nat er <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fomt to the appropriate governmental unit lax., apJ <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 d 7 SS <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel-4 <br /> 7-oao-}- y0-ib-47, <br /> grey racfS�tr poA�omo <br /> Property Owner's Mailing Address /4- 4q 5_Property Location <br /> 3bD(p0 L'��vrlmn �� Govt.Lot <br /> City,State Zip Code Phone Number /., Section a 7 <br /> Gf. ZJQ Cr F �✓� 7307 y�y 37 8775 (circle one) <br /> II.Type of Building pp y) T N; R i to E or <br /> yp g(check all that a 1 I e,rtr <br /> P1 or 2 Family Dwelling-Number of Bedrooms y ' Subdivision Name <br /> �bt r �h. <br /> ❑ <br /> Public/Commercial-Describe Use Block 4t" <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> M Town of O. le,/a. oe <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System i� 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 /> X 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(s0 Dispersal Area Proposed(st) System Elevation <br /> &4 . -7 Bs2 &M6/ gv.�, 4s. -7 53-4 <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units v c v o <br /> New Tanks Existing Tanks —y `v y <br /> d o 2 v R <br /> Septic or Holding Tank <br /> ,iso /aSo <br /> Dosing Chamber +/�6—0 <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/MPRS Number Business Phone Number <br /> Ze.c_-.uJ� o�/ -/ 1 -71If-- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> eL 770 0 //v 3 $ CxJe&,e/e t.�/� �'1f Fr 9 3 <br /> VIII.County/Department Use Only <br /> 121 Approved ❑ Disapproved Penni[Fee Date Issued Issuing Age 'gnature <br /> ElDen <br /> owner Given Reason for ial 375/kO ,?/d (L <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> S+ lS Gvrbkt« bcq SrAw aobodGdlvH ��+ dw-w M <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 inchUni e <br /> SBD-6398(R0313) BURNIM COUNTY <br /> ZONING <br />