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County <br /> ✓ �� Industry Services Division 3"frA t <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> Sill P.O. Box 7162 -q, <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 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 he used for secondary S6 ,7� <br /> purposes in accordance with the PrivacyLaw,s.15.04(I)(m),Stats. �w y 77 <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel N <br /> OAv< Ve ¢/•t~b�c ? —afS000 <br /> Property Owner's Mailing gildress Property Location <br /> l A 'oa /80-/� Se Govt. .3 <br /> City,State Zip Code Phone Number y,, y., Section !7 <br /> kI#m ball Al N �Sr 3T3 3Av -39d'- d39/ cleoney- <br /> It.Type of Building(check all that apply) 7 Lot k T y/ N; <br /> 1 or 2 Family Dwelling-Number of Bedrooms ,T Subdivision Name <br /> Block 9 <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Town of ,SwISC <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. � New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑` Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Penni[Transfer to New List Previous Permit Numberand Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that a I ) <br /> XNon-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,llis ersaI/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(s0 Dispersal Area Proposed(st) System Elevation <br /> qso ..7 G4'3 64t C 3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units D u o v o <br /> New Tanks Existing Tanks m u a <br /> C. <br /> Septic or Holding Tank .BOG Iowa <br /> Dosing Chamber _7 <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 /> /Zr alc /10 p let�, s /7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ol77G0 , .. 3S dv c6s�r. L✓S S`f8�13 <br /> VIll.County/Department Use Only <br /> Approved ❑ Disapproved �ennit Fee O G Dgate Issued Issuing Agent Sign re 1(:]6 <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> /il/eCL Sr�6a��s i d �Jrr� /ALL <br /> E <br /> Attach to complete plans for the system and submit to the County only ou paper not less than a 1 I ches in size <br /> FEB 14 SBD-6398(R0313) 2017 <br /> BURNETT COUIVTv <br />