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County <br /> Safety and Buildings Division �ju frYCf� <br /> D e_ 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number filled in by Co.) <br /> �SpS f Madison,W1 53707-7162 �Qa�l LL <br /> I <br /> Sanitary Permit Application State TransactionNumbcr <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Noce:Application forms for state-owned POWTS are submitted to Pmjcd Address(if different than smiling 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{ca(m),Stats. �/ Flo <br /> x, <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> / <br /> Property Owner's Mailing Address /� ,/ Property Location <br /> 1Z /�E:1 lrXj1'� Govt Lot <br /> City,State Zip Code Phone Number y, u S <br /> /��� �+j� �j /., Section <br /> /(0/eV/ew '// �� T / 1 N: R circle o S)n <br /> 11.Type of Building(check all that apply) Lot 2 w <br /> X1 or 2 Family Dwelling—Number of Bedrooms 7" 3 Subdivision Name f/ <br /> Block# aJn/seA'X dlverlGew r/� <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use 7Number ❑Village of , <br /> Townof <br /> 9 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A- New System ❑Replacement System ❑TreatmentMolding Tank Replacement Only Q Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal Q Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner �C <br /> /10F /tviout o.v <br /> IV.Type of POLVTS S stem/Com nent/Device: (Check all that a lv <br /> P'Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At Gmde ❑Mound>24 in.of suitable soil ❑Mound<24 is 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(gpdsi) Dispersal Area Acquired(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7 slZ� ' (z 9' � 6925 <br /> VI.Tank Info Capacity in Total #.of Manufacturer <br /> U a U <br /> Cullom Gallons Units E O <br /> U u y <br /> New Tanks Fxisung Tanks 2 <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VIT.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plants <br /> Plum s Name(Print) J/ Plum ig,naturo MPiMPRSNumbcr Business Phone Numbcr <br /> SSG--OZ.O Z <br /> Plumber's Address(Street,City,State,Zip <br /> 27Z2o <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signam <br /> S 7 7 <br /> ❑OwnerGivenReasonforDenial J7s' �0 q'"�.�— / a4�tZe <br /> IX.Conditions of Approval/Reasons for Disapproval 1 y/� //�/7 ,/ � j���ljf/ <br /> /1)0 �+leGG S�owti Ory /CIOI' �6QI1/j /vdf//S /irVs� /'/W IROE <br /> &:d <br /> ,4LZ Sete Se_I J4 e ef, S EP 13 201 <br /> Attach to complete plans for the system and submit to the County nNy an paper not less than 8 112 x 11 Inch p®� <br /> BURNETT COUNT <br /> SBD-6398(R.11/11) ZONING <br />