Laserfiche WebLink
BURNETT COUNTYV <br />SBD -6398 (R0313) 7niumira <br />Industry Services Division <br />County <br />(�t� v, ri Ce <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />P.O. Box 7162 <br />s <br />-, <br />�, '•�,� <br />Madison, WI 53707-7162 <br />�- <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 governinental 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 />I. Application Information — Please Print All Information <br />Property Owner's Name <br />^� <br />Parcel # <br />0 7— <br />Rte -A �S -e'Cv -Cry <br />X71- 5-.060 <br />Property Owner's Mailing Address <br />Property Location <br />� bS3 �M ,e leo 6/ Ra- <br />Govt. Lot <br />y y, Section S <br />City, State <br />Zip Code <br />Phone Number <br />JkN ttiv <br />g3(circle <br />one) <br />T yo N; R —� E orb <br />Lot # <br />II. Type of Building (check all that apply) <br />M I or 2 Family Dwelling — Number of Bedrooms <br />! P <br />Subdivision Name <br />�ST A 1 � NQ, �gJOL�i <br />Block <br />❑ Public/Commercial — Describe Use <br />1 <br />❑City of <br />❑State Owned —Describe Use <br />❑ Village of <br />CSM Number <br />X Town of SL� <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />System <br />Eefore <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B• <br />mit Renewal <br />❑ Pennit Revision <br />❑ Change of PlumberFO <br />Permit Transfer to NewList <br />Previous Permit Number and Date Issued <br />Expiration <br />ner <br />IV. Type of POWTS System/Component/Device: (Check all that apply) <br />it on Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Holding.Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />ZI.S' o 1 <br />._7 <br />6 413 <br />6e� r <br />Vl. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />o <br />New Tanks Existing Tanks <br />o <br />v <br />EU <br />In*„ <br />iV <br />a <br />Septic or Holding Tank <br />o.'• --O <br />�QS� <br />�h �� � N ti ��� <br />•/ <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />NIP/MPRS Number <br />Business Phone Number <br />R t IC- W,�e <br />a�.s8s, <br />s <br />Plumber's Address (Street, City, State, Zip Code) <br />o1776 o <br />VIII. Coun /De artment se Only <br />Approved <br />El Disapproved <br />Permit Fee <br />'Z7 <br />Date Issued <br />Issuing Agent Sid tore <br />❑ Owner Given Reason for Denial <br />--S <br />J7S " D <br />S Z) " j e <br />a� <br />IX. Conditions of Approval/Reasons for Disapproval <br />at Maim <br />, ECE V�' E <br />>r� np <br />Attach to complete plans for the system and submit to the County only on paper not less than 81/2 s 11 hes size 1U <br />BURNETT COUNTYV <br />SBD -6398 (R0313) 7niumira <br />