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^a+,aatr�+ja, ry �-- <br /> �� Safety and Buildings DivisionCoon Uwci- <br /> z' OS z; 201 W.Washington Ave.,P_O.Box 7162 Sanitary Permit Number(to befilled inbyCo.) <br /> `t PS ! Madison,Wi 53707-7162 <br /> Sanitary PermSlate Transaction Numberit Application �� a�iy'�1 <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 infommtion you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Ow ers Name Parcel# - <br /> Property Owner's MailinAddrre - Property Location <br /> Z,iZ47,5 wei1 /V C7J Govt.�Lot <br /> City,State / Zip Code /Phone Number Section <br /> _ > <br /> Z� <br /> c one�'Y #nclEo6� r T <br /> II.Type of Btrfldin (check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> 111111 Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number 11 Village of <br /> IWTownof (wew-I1g/yd <br /> III.Type of Permit: (Check only one box on tine A. Complete line B if applicable) <br /> A' ❑New System <br /> Replacement System ❑TreatrnenUHolding Tank Replacement Only 13 Other Modification to Existing System(explain) <br /> ❑Change of Plumber List Previous Permit Number and Date Issued <br /> B• <br /> Permit Renewal Permit Revision g ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S tem/Com nent/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade 9 Mound>24 in.ofsuitablesoil ❑Mound<24 in,of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersallfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y o /•o yid yso <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units P o d v <br /> NewTanks Existing Tanks o Z y o a <br /> a U in m m u. 0 0- <br /> Septic <br /> Septic or Holding Tank /00 <br /> Dosing Chamber ((���/ <br /> VR.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pill s Name(Print) 1 Plum ignatuurc MPiMPRS Number Business Photic Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> it AC11 <br /> VIII.Cour IDe artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued issuing Agent Signature <br /> 11 Owner Given Reason for Denial IS 3-75 6 �)-4)-16 31 S3 5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> DEC ENE <br /> r, 11 1ki - - -- nn <br /> Attach to complete plum for the system and submit to the Caonty only an paper not leas than 8 IxainAWhilsih <br /> BURNETTCOUNTY <br /> SBD-6398(R. 1 l/l l) ZONING <br />