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ON COMPUTER/SCANNED <br />+«ASU w ­11PIete pians mr ine system anti soonuc to the t,ounty only on paper not less than SM s l l inches in size <br />BURNETTCOUNTy <br />ZONING <br />SBD -6393 (80313) <br />Industry Services Division <br />County <br />fi Ids" <br />P <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />P.O. Box 7162 <br />f��lv3 I <br />Madison, WI 53707-7162 <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 />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (ifdifferent 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( I)(m), Stats. <br />— <br />%OpL o s. Dea1'.S 44,e- <br />,(GI. <br />1.Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # /b -- 03 <br />-mig-39— <br />I?oP1 Cmok <br />7 <br />Property Owner's Mailing Address <br />Property Location <br />I k-� C 1 Z4(4>^ 4,e <br />Govt. Lot -443 <br />y, y,, Section _- <br />City, State <br />Zip Code <br />Phone Number <br />P0-k/RIC 11r"64 dt� <br />S`to <br />cucleone) <br />Tg N; REor <br />II. Type Building that <br />Lot # <br />of (check all apply) <br />I or 2 Family Dwelling — Number of Bedrooms (/� <br />r <br />J <br />Subdivision Name <br />Block # <br />❑ Public/Cotmmercial — Describe Use <br />❑ City of <br />❑State Owned —Describe Use <br />❑ Village of <br />CSM Number <br />4 Town of Oh <br />I1I. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Pennit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS 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 Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (st) <br />System Elevation <br />300 <br />— <br />— <br />— <br />VI. Tank Info <br />Capacity in Total # of Manufacturer <br />Gallons Gallons Units <br />U <br />New Tanks Existing Tanks <br />0 Z <br />v <br />c U cn y <br />ii U <br />a <br />Holding Tank <br />d <br />�60D l JA// -e f e✓ <br />7raIC <br />3,1 d141it <br />%r! u 3.4.0 1 <br />Y <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 />-Y'-1 <br />Business Phone Number <br />gl e -ie- f/ i�..� _$�Z-L� <br />i� <br />),(J <br />s X66 -yrs- <br />Plumber's Address Street, City, State, Zip Code) <br />X764 01 . �, 1y.a61>rle,-7 <br />VIII. Coun [Department Use Only <br />Approved <br />❑Disapproved <br />Permit Fee <br />� O <br />Date Issued <br />Issuing Agent Signature <br />❑ <br />$ ? ` <br />76 <br />Q <br />' 7 <br />�Zwlt, <br />Owner Given Reason for Denial <br />v <br />/ p� <br />IX. Conditions of Approval/Reasons for Disapproval E ' E E <br />3ao.9aI Ah-eser w��� G;.v/er Amp., �11f (haler Gereret t <br />P10MJiivj t SPG CAia phr 38a <br />n <br />sEP z s 2017 <br />+«ASU w ­11PIete pians mr ine system anti soonuc to the t,ounty only on paper not less than SM s l l inches in size <br />BURNETTCOUNTy <br />ZONING <br />SBD -6393 (80313) <br />