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County <br /> 'p Xj Industry Services Division ke 1-14, <br /> # s Ill 1400 E Washington Ave Sanitm P unit Number(to be filled in by Co.) <br /> S P.O. Box 7162 87 1 <br /> Madison, WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.2](2),Wis.Adm.Cade,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 be used for secondary <br /> 2u!poses in accordance with the Privacy Law,s. 15.04(1)(m),Stats, <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name <br /> '.�' 7elett�-d-ti'IJ-IS-a�` <br /> 'PA r C�! e/l CaC c6790c6 <br /> Property Owner's Mailing Address Property Location <br /> 1W,S`H 5 a <br /> City,State Zip Code Phone Number Govt.Lot <br /> '/<, Section a 7 <br /> k/ ebli-r,' 1 -713-- '733 -b41,t 6 (circle one)., <br /> II.Type of Building apply) T N; R IS- Eo <br /> r�/ <br /> yp g(check all that a 1 Lot# <br /> ❑ Ior2Family Dwelling-Number ofBedrooms P tmSubdivisionName' I / , / <br /> �- _{--y , <br /> Public/Commercial-Describe Use tllock ff fUe7�� ��tJ <br /> vv— <br /> City-�- ❑ City of _ <br /> ❑State Owned-Describe Use CSNI Number ❑ Village of <br /> ® Town of--JA",MS/sry <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System ❑Treatment/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 /> IV.Type of POWTS S stem/Com onent/Device: (Check all that apply) <br /> wNan-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.ofsuitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) _ __ ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdst) Dispersal At ea Required(s0 Dispersal Area Proposed(st) System Elevation <br /> :?a v . -7 e-0 1 `y-5-/ dal.Jf <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New TanksExisting Tanks �m Q U <br /> 'o <br /> c U in v rn w V n. <br /> Septic or Holding"Tank T ,+ <br /> - NfiAt c-jKd <br /> Dosing Chamber <br /> VIL 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 /> IT I e-le- /t/a le 1 h s <br /> �dssa I 7�s �c-his <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77 3S" �ivebsfr� Gti J�Gf�S <br /> Vill.County/Department seOnl <br /> Approved ❑ Disapproved $Permit Fee �� Date Issued / Issuing Agent Signa re <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the Countyonly on paper not less than I inches in siz <br /> JuL1 JVlois <br /> SBD-6398(R0313) BURNETT COUNTY <br /> ZONING <br />