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County <br /> Industry Services Division 14-Y <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> n sP P.O. Box 7162 <br /> Madison, WI 53707-7162 <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 governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms Car 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. 15.04(1)(m),Stats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel p �!' JOS-- <br /> .SCOT �ykkl e7—odo—l- o-iG3 <br /> ai,s_ oi6pao <br /> Property Owner's Mailing Address <br /> i Property Location <br /> yJ/O 0 �C Govt.Lot <br /> City,State Zip Code Phone Number y,, y,, Section <br /> 33 <br /> _1'-C/5%q 3 (circle one <br /> PPY) <br /> II.Type of Building(check all that apply) Lot# oU�� <br /> (/ <br /> I or 2 Family Dwelling-Number of Bedrooms 6 OL 7 Sub ivision Name lul/_�,LS 64 <br /> Block# (j� c �Vf7 <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of n c/G/6 n Gt! <br /> II1.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Replacement System ❑ Treahnent.'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 /> If .Type of POWTS System/Component/Device: (Check all that apply) <br /> on-Pressurized In-Ground [IPressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑Ho ding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Desigi3Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sO Dispersal Area Proposed(st) System Elevation <br /> 4 61-�"_d . 7 1 G ZO 49�v8 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o '� <br /> New Tanks Existing Tanks 2 ro <br /> Septic or Holding Tank /OI JD 00 ,/�J/r,5 C ,• <br /> Dosing Chamber <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 NIP/MPRS Number Business Phone Number <br /> /�LG le— /d ��/f7 -f ;—>- rF l� OfS�.S—/ 7/.S—�G�-✓{/S7 <br /> Plumber's <br /> Address(Street,City,State,Zip Code) <br /> J <br /> VIII.CountyfDepartment Ilse Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signs e <br /> ❑ Owner Given Reason for Denial <br /> $.3 <br /> IX.Conditions of Approval/Reasons for Disapproval t/LL [JD�7eJ>`,� G(f�t/ L �A�l✓// /1/PPds �/o Go %o SQ�vi/t4� ECE � V�/f <br /> E <br /> rPwt•I� S�f�l.rt� �.�.c��d'N� �l�k ✓eom �Lw G'a ra� � . D <br /> Attach to complete plans for the system and submit to the County only on paper not less than S Ia I in sin <br /> BURNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />