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County <br /> Industry Services Division 13 L& r N �� <br /> 47- <br /> s <br /> #t ps ;' 1400 E Washington Ave Sanitary Permit Nwnber(to be tilled in by Co.) <br /> *' +ti pS #j P.o. Box 71sz <br /> L` .• Madison,WI 53707-7162 <br /> Sanitary Permit Application Suite Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 2?020(P7 <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 a-7 3 7.S <br /> u oses in accordance with the Privacy Law,s.15.04(1)(m),Stats. '^� <br /> 1. Application Information-Please Print All Information C/�✓r�S G(C /7/ <br /> PropertyOwner's Name Parcel <br /> arcelti d a - �,HO_�w� 3 S•S pS'd a l <br /> � ` Oj�vY �N[7WlIMCV —U01 � BdfOhb <br /> Property Owner's Mailing Address Property Location <br /> !,S /bo Pecewthe.• 0Govt.Lot—7 <br /> City,State Zip Code Phone Number Section 3,5` <br /> '7 (circle one <br /> �` (9SC !"✓I Ot, T 1/0 N; R /(o Eor <br /> II.Type of Building(check all that apply) Lot# <br /> Q I or 2 Family Dwelling-Number of Bedrooms 3 _ ! � Subdivision Name <br /> Block# <br /> ❑Public/Cotmnercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number <br /> � ❑ Village of <br /> (/ r.tom Town of Ca k lA etd <br /> III.Type of Permit: (Check only one box on line A. Complete line R if applicable) <br /> A. ❑ New System 14 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 Dale Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Com ponent/Device: Check all that a l ) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade Tr 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 Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> YJ /, 0 ysv ys-v 9r.s <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Fxisdng Tanks ce <br /> c U y rn <br /> Septic or Holding Tank <br /> Dosing Clumber <br /> VII.Responsibility Statement- 1,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 /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Penni[Fee_ O Date Issued Issuing Agent Signs <br /> m e <br /> 11Owner Given Reason for Denial $-376. ,- S^/LO y�(.D <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECENE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/?x 11 in bLLipfitze <br /> MAY 16 1016 <br /> SBD-6398(R0313) BURNETT COUNT`! <br /> ZONING <br />