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x X49 ; <br />/ <br />7� 43 ra <br />Industry Services Division <br />County <br />i3 µ r n <br />� <br />Ave Washington 1400 E <br />9 <br />P.O. Box 7162 <br />Sanitary Permit Number (to be Pilled in by Co.) <br />P <br />SAN_ 13_0,? <br />' <br />Madison, WI 53707-7162 <br />GQ 7a <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis, 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 pen -nit. Note: Application forms for state-owned PO WTS are submitted to <br />the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br />d 9993 <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />/M Ie) err✓a <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel #p 0 <br />07-a34-I-LiI-/�•3S= 1- - Oi,l <br />j�ac.l 44,ty� <br />oOd <br />Property Owner's Mailing Address <br />Property Location <br />/^ <br />.q✓e L <br />Govt. Lot <br />/ <br />dLL1� d�� /, Section 3•� <br />AZA <br />City, State --[Zip <br />Code <br />Phone Number <br />/V, A/. <br />SS/041 <br />7 D 6 <br />/�_ d ��- 3 <br />— <br />(cu-cleone <br />T y/ N; R 16 E otV <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />l or 2 Family Dwelling - Number of Bedrooms <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑State Owned -Describe Use <br />❑ Village of <br />CSM Number <br />V 9 P � <br />Town of Sw/sS <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System y <br />®Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />El Other N[oditication 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 />Cl �� yS/ 5--3-9Z <br />IV. Type of POWTS System/Component/Device: (Check all that apply) <br />Non --Pre §sl uHzed In -Ground ❑ Pressurized [n -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ HoldiniTank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersl/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal AreaRequired (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />�oC) <br />S <br />/,too <br />1 00 <br />-7 J.3 td 9-4•-7 <br />VI. Tank Info <br />Capacity in Total <br /># of Manufacturer <br />Gallons Gallons <br />Units <br />y <br />New Tanks <br />Existing Tanks <br />v <br />Y <br />a U <br />vi ti <br />vt <br />u. V a <br />Septic or Holding Tank <br />1700 <br />Ile,0 <br />Dosing Chamber <br />?40 i% <br />8O0 <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the PONVTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />A <br />MP/MPRs Number <br />Business Phone Number <br />-zf/rS"7 <br />Z/cl"- tj&/ kIH s <br />/'Z_ . <br />�s"8�`l <br />7/.f >�66 <br />Plumber's Address (Street, City, State, Zip Code) <br />7760 3.r W_c�s7l`4✓ WL (:�- `J?13 <br />VIII. County/De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee O <br />Date Issued <br />Issuing Age=ia <br />❑ <br />37s° <br />Owner Given Reason for Denial <br />IY. Conditions of Approval/Reasons for Disapproval E � I V E <br />D <br />FEB 0 6 2018 <br />.mit .1 1 1. 1uwN,eie Awns wr ine sylieIll unu sit uuui to Lae uounry omy o paper not less than 8 1/2 s l l inMes in size L� J <br />BURNETT COUNTY <br />ZONING <br />SBD -6393 (R0313) <br />