Laserfiche WebLink
County <br /> Safety and Buildings Division <br /> Sanitary Permit Number(to be filled in by Co.) <br /> A.- I)e 201 W.Washington Ave.,P.O.Box 7162 <br /> Madison,Wl 53707-7162 <br /> L <br /> Sanitary Permit Application State TransactionNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate govcmmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PONVTS 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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stars. <br /> 1, Application Information-Please Print All Information V/7? 7):txi• rJ <br /> Property Owner's Name Parcel' <br /> borM04 Co vrf 07-018 447-107-1 0 11 "0--61106\ <br /> Property Owner's Mailing Address Property Location <br /> RIP 65 Zel k- Govt.Lot <br /> City,slate Zip Code Phone Number 30 141 AP 49 1K, Section_3r Z <br /> 6�reJ . -Ai8 72 ..relycmc <br /> tW4 T N; R E or � <br /> -, <br /> 11.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block <br /> El Public/Commercial-Describe Use 11 City of <br /> ❑State Owned-Describe Use CSNI Number El Village of <br /> V2Z Pal- KToxvn of IleewonJ <br /> III.Type of Permit: (Check only one hox online A. Complete line Rif applicable) <br /> A. New System ❑Replacement System ❑TrcatmentJHoldine Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 11 Permit Renewal ❑Permit Revision ❑ Change of Plumber El 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 0 Pressurized In-Ground 0 At-Grade 11 Mound>24 in.ofsuitable soil 0 Mound<24 in.ofsuitable soil <br /> Holding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons units o U C <br /> t; <br /> New Tanks Existing Tanks = 0 <br /> 0 := E 2 <br /> I U M 7; CO L-- 0 a. <br /> Septic or Holding Tank <br /> Dosinu,Chamber 1Z oft> lzat)l .5 AWW Y <br /> V11.Responsibility Statement-1,the undersigned,assume responsibility for installation or the PONVTS shown on the attached plans. <br /> Plum 's Name(Print) Plumb ignaturc MPJ`MPRS Number Business Phone Number <br /> 17 <br /> ^ 65f D7 1/5-SM-02-0 Z- <br /> Plumber's Address(Stmet,City,State,Zip Code) <br /> Z Z:Z 0<--) -�-<a P-,?"-.C 3^( iR�Cdl J" 5�"9 <br /> Vill.Countyfl)epartrrtenit Us-e--Oni-y <br /> AApproved [I Disapproved Permit Fee p Date Issued Issuing Agent Signa re <br /> I C1 Owner Given Reason for Denial 1 -3 <br /> IX.Conditions of ApprovalfReasons for Disapproval <br /> V rp <br /> L& <br /> Attach to complete plans for the system and submit to the County only on paper not ess than 8 If-,x 11 Inc <br /> SBD-6398(R. I Ill 1) yl APR 0 9 2018 <br /> BURNETT COUNTY <br /> ZONINrl <br />