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cottlmWC0-WL90V SafetyapdBuiltimgsDivision County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> gq C Madison,WI 53707-7162 Sanitary Perm Number(to be filled in by Co.) <br /> . rt»pa� *- 72, <br /> Sanitary Permit Application State Transact on Number <br /> In accordance with s.Comm.83.21(21 Wis.Adm.Code,submission of1hia Path to the appropriate govert meatal <br /> unit is required prior to obtaining a sanitary permit Note: Appli n form for state o ned POWTS are Project Addm (if different than mailing address) <br /> submitted to the Department of Commerce. Petaoml information you provide may be used for secondary <br /> purposes,in accordance with the Privacy Isco a.15. t m Stats. <br /> I. A lication Information-Please Print All Information <br /> Property Owoer'a Name Parcel# <br /> SoNrt LARSEr1 o14-7 13-oz-400 <br /> Property Owners Mailing Address 11 Property on <br /> was 3otS Cv AwLVr I%le, Govt Lot <br /> 7n-- <br /> City,SC �,,r1 Zip Code Phone Number �E '/., Lj %t Section 1_ <br /> S1 P4LLL. 1 r rf1 z5 ii7 �p$ - 3- l(v�Z T �8 N R cirolE one <br /> l_ <br /> Type of Building(check ail that apply) Lot# �y <br /> 1 or 2 Family DweWng-Number of Bedrooms 3 Subdivision Ni <br /> Block# <br /> ❑Public/Commmcial-Describe Use _ ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of r- <br /> A Town of T C UxTrE <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' /'New System Replacement System TreamiwVHoldm Tank <br /> Replacement Only ❑Other Morfil ration to Existing System(explain) <br /> B. ❑Permit Renewal ❑PemritRevision ❑Change of Plumber ❑Permit Trmsfarm New List Previous Pi rinit Number and Date Issued <br /> Before Expustion - _ Owner <br /> IV. ofPOWTSS endCom meattDevice: Check all that apply) <br /> Nan-Pressuriad In-Ground ❑Pr wi=d hr-Gmmd 4 At-Grade ❑Mound>24 in.ofsuitable soil ❑Mound<2 in of suitable soil <br /> ❑Holding Teak '❑Other DispeOWComponW(explain)- ' ❑Pretreatment Device(explain) <br /> V.Dis ersalfrreatmeutAreaIaformation: <br /> k9Design Flow(gpd) Design Soil Application RaWjpdsf) Dispersal Area Required(so Dispersal AProposed(at) System Elevation <br /> 50 7 ,' res 643 1 LSo 2! 84.b' < So.bI <br /> VL Tank Info T Capacity in Tend #of Manufacturer <br /> . Gallom Gallons Units <br /> New Tammsepticmrfiow - :aristimg TsNu S 8 b' 'd <br /> tg rn Yn � 'w 3 w <br /> ""� l0 0 0 10 1 <br /> I>osuy(3smbet <br /> VIuLm bRtae�s�yo�nasiabail�i t�Statement-1,the rndecigred,assume natbility for Installation ofthe POWIS shown on the arta ed plans. <br /> PI I &r� s7Cf"I IC & EXCAVATI1 aS MP/MPRS Number Business Pbone Number <br /> as s�879 <br /> Plumbers AtlernlBreaer6iviethr7i ) <br /> VDI.Coss ety/�/Deepa1l�\t�CtmeSSntIUYse Oaa77n"l . <br /> f;'rApproved 1 ❑Disapproved Permit Fee Date Issued Issuing Si <br /> ❑Owns Given igis rorDmial s �� MA 8 26,7 , <br /> IX.Conditions of Approval4tessons for Disapproval <br /> I -`�� <br /> "'AY 72007 U, <br /> Ananh to complete pians for the system and submit WAImlComaty only on paper not Iw than a la a 1 chm in . <br /> BURNETT COUNTY <br /> SBD-6398(R.01/07)Valid thin 0v0v ZONING <br />