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County Jt- <br /> Safety <br /> and Buildings Division <br /> r►?; 0 •�+"'. 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `w $P r� Madison,WI 53707-7162 <br /> Sanitary Permit Application Sate Trans [ioLn Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Gfd.� <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(ifdifferent than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may he used for secondary ^ <br /> ur ses in accordance with the PrivacyLaw,s. 15.04(1 m),Stars. ���� �I✓`aVf f <br /> 1. Application Information-Please Print All Information ` <br /> Pro pe Owner's Name Parcel H 07-02p.Z,afp.�b-34..5 I5,CJ0.a <br /> a <br /> VV_ .af Ca �S 6Zo9 IOD <br /> Property Owner's Mailing Address <br /> Property Location <br /> ao aG 6 Govt.Lot <br /> City,State Zip Code Phone Number Ji <br /> /, Section 77 <br /> lJ wf cb 78o-y32 (circle one <br /> 11.Type of Building(check all that apply) Lot# T �� N; R 1�E or <br /> II or 2 Family Dwelling-Number of Bedrooms /' Subdivision Name <br /> Block# sAA PF' Ol <br /> ElPublic/Commercial-Describe Use <br /> ❑ Ciry of <br /> El State Owned-Describe Use CSM Number ❑ Village of ^ <br /> IFx 0" <br /> Town of <br /> lawd <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 El Other Modification to Existing System(explain) <br /> B. i] Permit Renewal ❑ Permit Revision ❑Change of Plumber i]Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> 9 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal freatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units ro v <br /> New Tanks Existing Tanks20 <br /> i c <br /> Septic or Holding Tank A o <br /> Dosing Chamber VV <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu 's Name(Print) PlumSig Ze MP/MPRS Number Business Phone Number <br /> /o a r ✓ 5' S 6G-t�v <br /> Plumber's Address(Street,City,State,Zip Co <br /> Z7=to Tolni5 ry LfI 9 <br /> VIII.Coun /De EDipp!oved <br /> t Use only <br /> Approved ❑ Permit <br /> nFee Grp /Date Issued <br /> Issuing nt gnature <br /> ❑ Given Reason for Denial $ /5 (O <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 17 <br /> Eros � <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IR esM- <br /> SBD-6398(R. II/11) BURNETT COUN'T`S <br /> ZONING <br />