Laserfiche WebLink
County <br /> Industry Services Division t7(c r n G <br /> 7` IDS'. 1400 E Washington Ave Sa tary pesout t�ymber(to be tqd in by Co.) <br /> p 3 w P.O. Box 7162 {� <br /> yX, Madison,WI 53707-7162 4 SS <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govetrunental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal utfonuatioa you provide may be used for secondary 9-719 <br /> purposes m accordance with the PrivacyLaw,s.15.04(I)(m),Stats. / <br /> I. Application Information-Please Print All Information (rr<erl-4 rCG rna-t <br /> Property Owner's Name Parcel 4 <br /> J err Swa0 e/C 036-' YY/.3- 0&700 <br /> Property Owner's Mailing Address Property Location/ <br /> Alf /a 3�d C1Y• Govt.Lot Sa 6 <br /> City,State Zip Code Phone Number l Section /3 <br /> n I /, /<, <br /> GGoH /vAl(j(OeS MN SSyY.f (circleone) <br /> T__y,0 N; R_1 For <br /> 1I.Type of Building(check all that apply) Lot# <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms d Subdivision Name <br /> Block 4 <br /> ❑Pubtic/Cormnercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number o /g/ 7 ❑ Village of_ <br /> V. /q pd.5-:4 Town of 64A ce rl <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New S stem y ❑ Replacement System ❑Treatmem/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 System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized fn-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.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Sail Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> q,S'o , -7 (9 eY3 lv z/90 171.6 v, 90. 7 <br /> VI.Tank Info Capacity in Total of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tatilcs .2 .- <br /> ` <br /> Z <br /> Septic or Holding Tank �6p0 JS OQ W J C 5"d <br /> Dosing Chamher <br /> VIL Responsibility Statement- I,the undersigned,assume responsibility for installation of the POVYTS shown on the attached plans. <br /> Plumber's Name(Pant) Plumber's Signature MPIMPRS Number Business Phone Number <br /> ,zl e-Ae flap�i,�s IZ441- // a, s�s-i 7ars.rJ,,4- vi.s-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77 <br /> VI11.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Pee 3 Date Issued Issuing Agent Signature <br /> ❑ <br /> Owner Given Reason for Denial 7S 7- <br /> IX.Conditions of Approval/Reasons for Disapproval InJUN <br /> �0 E I q /�BE 0 5 2017 ID <br /> Attach to complete plans for the system and submit to the County only on paper not less than S r2 x inche. in size <br /> BURNETT COUNTY <br /> ZONING <br /> SBD-6398(R0313) <br />