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CSN COMPUTERISCANNED <br />SBD -6398 (R. 11/11) <br />BURNETT COU NTy <br />ZONING <br />County <br />Safety and Buildings Division <br />�? <br />201 W. Washington Ave., P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />SPS <br />=i <br />Madison, WI 53707-7162 <br />; <br />/ <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(3), Vis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <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. <br />1. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />Teo ge(jer <br />-Z- -11411 Z 0*00-0/ /00 <br />Property Owner's Mai/tn��g Address <br />Property Location <br />6G �' 40 • 0. f <br />Govt. Lot `1 <br />/, w y,� Section I �'/ <br />City, State <br />Zip Code{ <br />Phone Number <br />f _ <br />71✓-[�3�Z�� <br />T��N. R irclEo e r <br />1I. Type of Building fcheck all that apply) <br />Lot # <br />Subdivision Name <br />❑ 1 or 3 Family Dwelling -Number of Bedrooms <br />Block <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned -Describe Use <br />❑ Village of / /- <br />XTown of M/t1//_ ^11419-14 <br />CSivI Number <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />ElNew System <br />XRepiacement System <br />TreatmentiHolding Tank Replacement Only <br />Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber❑ <br />Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />�NV� <br />IV. Type of POWTS S stemlCom onent/Device: (Check all that appiy) <br />Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ bfound > 34 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} <br />Design Soil Application Ratefgpdso <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />. 7 <br />yZ9 <br />yZ°7 <br />y . <br />VI. Tank info <br />Capacity in <br />Total#of <br />Manufacturer <br />Gallons <br />Gallons Units <br />o <br />u <br />NweTanks Existing Tanks <br />u a C <br />U in <br />y a r <br />vt i2 U c <br />Septic or Holding Tank <br />76-0 <br />I A- <br />76-0 <br />W c p <br />Dosing Chamber <br />tetint <br />k4t-i <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plum s Name (Print) <br />Plumber' aturc� <br />MP/MPRS Number <br />Business Phone Number <br />r 1!7 D� c 2� <br />/ <br />Plumber's Address (Street, City, State, Zip Code) <br />Z 7z2AD W&/..5 1„ 1 r 5-119F <br />Vlll. County JDe artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Signature <br />C1 Owner Given Reason for Denial <br />S j y/' p 0 <br />�/ / <br />IX. Conditions of ApprovallReasons for Disapproval <br />E fiR I <br />'Inn OCT 13 20P <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 tR x 11 inches si <br />SBD -6398 (R. 11/11) <br />BURNETT COU NTy <br />ZONING <br />