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-:.,iy-vsnirr�. County <br /> Safety and Buildings Division <br /> D5 � 201 W.Washington Ave..P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> IA- <br /> PS sTi Madison,WI 53707-7162 �nl /���.//tt• <br /> Sanitary Permit Application State TranssaactiionNumbber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 2 7/3S-?4 <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 /> purposes in accordance with the Privacy Law,s. 15.04 1)(m),Stats. !Q(P ��` <br /> 1. Application Information-Please Print All Information H/,v <br /> Property Oer's Name Parcel# <br /> u 01\jS- <br /> Property Owner's Mailing Addrressp Property Location <br /> W 1186.1 ! 6 Govt.Lot <br /> City, to Zip Code Phone Number , , Z <br /> ..((//;;��,,�� / ► �j� p �r Section <br /> tVe^IOW '�t <br /> 7140 Z_ 6�2-'AZO-Po'(Z Ftp N; R lrciconc <br /> ♦ I <br /> II.Type of Building(check all that apply) Lot# T E <br /> V1 or 2 Family Dwelling-Number of Bedrooms / Subdivision Name <br /> r <br /> fl e5 <br /> ❑Public/Commercial-Describe Use Block# 5,5ua <br /> ❑City of <br /> ❑ CSM Number ❑Village of <br /> iffState Owned-Describe Use � / <br /> Town of df04J%v+ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System y 'Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑Change of Plumber List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal El Permit Revision g ❑Permit Transfer to New <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 /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Pow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> /40 <br /> 1Dd 3Q� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units Z <br /> Nev Tanks Existing Tanks <br /> ti p H U <br /> c. <br /> Septic or Holding Tank .rte <br /> Dosing Chamber t7An�/ <br /> =F= <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) ff PIU509S Signa®�, MPiMPRS Number Business Phone Number <br /> 7G��/ l BS�gS 7i -5G(-oz.a Z <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signa re <br /> ❑Owner Given Reason for Denial S 37S. / " „ / I /V./0- �Le_4,p <br /> IX.Conditions of Approval/Reasons for Disapproval c <br /> D E(01;EUV <br /> Attach to complete plans for the system and submit to the County only on paper not len than 812 a 11 inches in size <br /> OCT 1 1 2016 <br /> SBU-6398(R. 11/11) BURNETT COUNTY <br /> ZONING <br />