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BURNETT COUNTY <br />SBD -6398 (1103 13) ZONING <br />County <br />°ra <br />Industry Services Division <br />uS, N <br />,gid <br />' SPS` <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />P.O. Box 7162 <br />5 `1 -4a <br />INk <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 (if different than mailing address) <br />the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br />733 <br />purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. <br />I. Application Information - Please Print All Information <br />l/-GVI <br />Property Owner's Name <br />Parcel # <br />67—adv--at- d o/G-3y-SvS- oa,� <br />1% �� ti 1 S �r'j's a�t�� <br />-ars000 <br />Property Owner's Mailing Address <br />Property Location <br />9//.4 P 1sC /G <br />Govt. Lot at ,- f t� <br />y, y,, Section ? f <br />City, State <br />Zip Code <br />Phone Number <br />8106M t, Al <br />5'rg3 9 <br />(circle one <br />T yrJ N; R � _ E o <br />Lot # <br />Il. Type of uilding (check all that apply) <br />,Jr� <br />Subdivision Name <br />in I or 2 Family Dwelling - Number of Bedrooms <br />6T <br />Block # <br />❑ Public/Cornmercial - Describe Use <br />11 city of <br />❑State Owned -Describe Use <br />❑ Village of <br />CSM Number <br />LI <br />,R Town of CQ1<1a.vtOt <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />/t Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Moditication to Existing System (explain) <br />B. <br />El 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 />A,' Ir. <br />IV. T e of POWTS S stem/Com onent(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 (so <br />Dispersal Area Proposed (st) System <br />Elevation <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />Gallons <br />Gallons <br />Units <br />o <br />New Tanks <br />Existing Tanks <br />0 4 <br />Y R <br />a <br />U ch, <br />C� <br />Septic or Holding Tank <br />'ks^a� <br />t�yp <br />O� <br />I.(/�rs r� <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 />MP/MPRs Number <br />Business Phone Number <br />71 IS <br />Plumber's Address (Street, City, State, Zip Code) <br />,? 77G0 �/ 3S GrJe6Y,- 1,v Syf g 3 <br />VIII. Cour /De artment Use Only <br />Approved <br />El Disapproved <br />Permit Fee <br />$ <br />Date Issued <br />Issuing Agent Signae <br />❑ Owner Given Reason for Denial <br />3 7S• <br />IX. Conditions of Approval/Reasons for Disapproval <br />D E%` EVE <br />Attach to complete plans for the system and submit to the County only on paper not less than Ua x inche m ize <br />BURNETT COUNTY <br />SBD -6398 (1103 13) ZONING <br />