Laserfiche WebLink
Industry Services Division County <br />4 `�_ `� , 1400 E Washington Ave <br />i" P.O. Box 7162 <br />Sanitary Petmit Numberto be filled <br />Madison W153707-7162 I g_ 3 1 Y <br />it <br />- _ <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 governmental unit <br />is required prior tof obtaining a sanitary permit. Note: Application forms for state owned POWTS are. submitted to Project Address (ifdifferent than mailing address) <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />u to accordance with the Priv Law, s. 15.t? 1 )(in), Stats. <br />I. Application Information - Please Print All Information Z-/q34 Pim C A) E LAA; 4;- <br />Property Owner's Name <br />AL— Parcel # <br />Yf1 AD.AN«K d7-03b-Z-�iYI-i7-30 <br />Property Owners Mailing Address %Dec <br />I SZ-3Z J40"41 A✓F1VUE +'J Location <br />City, State Zip Code Phone Number <br />Govt. Lot <br />AAA5 T V4, — �sl Ly 1P, Section 3C11 1 t <br />IL Type of Bnikiing (check all that apply) Lot # T _j E �_N; R 17 circle oj_W1 <br />J <br />1 or 2 Family Owelling - Number of Bedrooms 3 / <br />Subdivision Name <br />❑Public/Commercial- Block 1�Xr;Wepp PLAVI..ATt <br />Describe Use , <br />11 <br />El State Owned - 131=16-cCity o Use CSM Number 1 <br />— — -- _ 0 Village of <br />III. T Town of LL ki l <br />Yl� of Permit: (Check only oite bol on line A. Complete line B if applicable) <br />A. New System ❑ Replacement System ❑ Treatmentiliolding Tank R l <br />cp acernent Only 1 ❑ Other Modification to Existing System 4exlrl Irl <br />B• ❑ Permit Renewal <br />!] Permit Revision ❑ Chan of Plumber List Pre%Kaus Permit Number and Bate Lwted <br />Before Expiration Permit TransieY to New <br />IV. T of PO�VTS System/Com nent/Uevice: Owner <br />Non"Presstvized Cheek all that apply) <br />[n-Ground <br />Pressurized In (,round ❑ At-Grade ❑ Mound > 24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersali] Mound < 24 m, Of suitable Sniff <br />Component (explain) <br />V. Dis rsal/ Treatment Area Information ❑ Pretreatment moire {'explain) <br />Design Flow(gpd) Design Soil Application Ratet fi <br />.� -, Dispersal Area Required (sf) <br />VI. Tank Info Z. �� Bursal (st) SN Elevanoil <br />Capacity an Total # of <br />Gallons t <br />New Tanks E Tanks Manufacturer Gallons Units "'T""----f-- <br />xtsmtg v <br />Septic n� -0 0 5 <br />1R zY C+ <br />Dosing Chaurber o� 'v v ;6+ <br />� (loo � w ►�5�-- ✓' ,y ,�+, , <br />VII. Responsibili <br />Plumber's N � Statement- 1, the a$dersig�d, aas <br />ame (Prirt) respo ty for installation of <br />C6K Plum s Si the PO►� f S shown on n attached pbn& <br />--J�LfI'�t�V MP <br />Plumber's Address kaveet, City, State, Zip Code /MPR$ Number i Buster Phone Number <br />q f3� %�� <br />`D� >4CK BP,GbK ftp- ?C/1 <br />VIII. CouB !De rtment Use Onl <br />Approved <br />❑ Disapproved f <br />Permit Fee as Date Issued <br />IX. Conditions a Owner Given Reason for Denial Issuing Agent Signatu <br />X- 4 Pprovol/Reasons for Disapproval <br />x/, G,�LL Co�a7`ieI f% <br />Attach to complete Iutany farthe system a� submit to the ComeMVE <br />ty 0-4'04 Paper not less #ban 8 <br />SBD-(398 y rze <br />(R. 08114) MAY 0 7 2018 <br />BURNETT COUNTY <br />ZONING <br />