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ON COMPUTERISCANNED <br />,... Safety and Buildings Division <br />County <br />gwet <br />Sanitary Permit Num r (to be filled in by Co.} <br />�����j{ <br />201 W. Washington Ave., P.O. Box 7162 <br />SP +! Madison, WI 53707-7162 <br />f <br />•7. <br />/ <br />�l <br />FS .1�,. f � <br />1 / • 1 <br />" <br />y Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission ofdtis form to the appropriate governmental unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />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. <br />Ct <br />Parcel m <br />1. Application Information — Please Print All Information <br />Property Owner's Name <br />io' l �h <br />Property Owner's Mailing address <br />rii <br />:Nt <br />Property Location <br />V , D ,Vttrj_ <br />Govt. Lot 7 9 <br />'/, Section�+ <br />Cit, , tate <br />Zip Code <br />Phone <br />l�L ' , r <br />ne�J_h VV �` <br />"Ic.IGI <br />�s�-Lyl-��yG <br />/ `v,, <br />�,�Z <br />T (l V N R circlEoonC�i� <br />II. Type of Building (check all that apply) <br />Z <br />Lot r <br />Subdivision Name <br />1$1 or Z Family Dwelling —Number of Bedrooms <br />/ <br />ooh, / ;,' - , <br />Block = <br />❑ City of <br />❑ Public/Commercial — Describe Use <br />❑State Owned —Describe Use <br />❑ Village of <br />IYTotvrt of <br />CSM Number <br />III. Type of Permit: (Check only one box online A. Complete line B if applicable) <br />A- <br />New System <br />❑ Replacement SystemP <br />❑ Treatment/Holding Tank Replacement Only <br />Y <br />Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />13Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POINTS System/Component/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 Tawk ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsO <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />o <br />_ 1-7 <br />�z7 1 <br />42 <br />iy. 127 <br />VI. Tank Info <br />Capacity in <br />Total <br />r of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />C <br />I <br />U <br />b <br />New Tanks <br />ECistingTanksv <br />b <br />C U <br />[n n <br />u <br />rn <br />L• U G <br />Septic or Holding Twik <br />/ \ <br />!"Y \ <br />I <br />w <br />Dosing Chamber <br />VII. Responsibility Statement— 1, the undersisned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plum s Name Print Plumber' nature MPMPRS Number Business Phone Number <br />�� 7, -02-0 z. <br />Plumber's Address (Street, City, State, Zip <br />�C/ode) / <br />Court e artment Use Oniv <br />TA,Pproved <br />❑ Disapproved <br />Permit Fee .— G <br />S 37�. ° <br />Date Issued <br />/o -s �7 <br />Issuing Agent Signatu <br />VJ <br />❑ Owner Given Reason for Denial <br />IX. Conditions of Approv/al/Reasons/for Disapproval <br />�Q <br />EG <br />\'7 <br />// / �u(°r <br />Sys�ern le/N3 rvs1A Cl -f //1APT <br />n <br />,/ <br />il 9 ini i <br />At to complete plans for the system and submit to the Caunh only on paper not tens man a u-, x ji men sicyv i v v L U 1 f <br />V <br />BURNETT COUNTY <br />SBD -6398 (R. i Ill 1) ZONING <br />DO <br />