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,:1 �:. •r1= ja <br />._-- <br />Safety Buildings Division <br />County <br />/Nd1l- <br />and <br />V <br />�?`�: <br />201 W. Washington Ave., P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />Madison, WI 53707-7162 <br />S fj N L <br />i <br />1% _ <br />Sanitary Permit Application <br />State Transaction Number <br />accordance with SPS 383:21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />4r—isIn <br />141A,— <br />Project Address (if different than smiling address) <br />isrequired prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <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. I5.04(t)(m), Stats. <br />I. Application Information — Please Print AU Information <br />Property Owncr's Name <br />Parcel <br />/ <br />are�v �iC�rrx�ek <br />Property Owner's Mailinge Address <br />Property Location <br />n <br />11'eA <br />179153y �l{Pi <br />Govt. Lot <br />'/� , /�, Section <br />City, State <br />P <br />Zip Code Phone <br />Number <br />�N�t:� <br />r�9 <br />�+ <br />-Z ^% jr?-7 <br />.I.- Alt) N. R � citclE or� <br />-�— <br />H. Type of Building (ch Ic all that apply) Lot" <br />I or 2 Family Duelling -Number of Bedrooms 7s <br />79 <br />Subdivision Name <br />Block= <br />" Z,1, a <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned -Describe Use CSbI <br />C1 Village of <br />Number <br />RTotvrt of , RG1��9a11 <br />III. Type of Permit: (Check only one bot on line A. Complete line R if applicable) <br />A. <br />❑ New System <br />lyRe lacement System <br />p <br />❑ Treatmentl.Holdine Tani: Replacement Only <br />❑Other Modification to Fasting System (explain) <br />B. <br />❑ Permit Reaettal <br />❑Permit Revision <br />❑ Change of Plumber <br />11 Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of PODVTS SystemlCom onent(Device: (Check all that a Iv} <br />WNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound >_ 24 in. of suitable soil ❑ Mound <24 in. of suitable soil <br />❑ Holding Tato: ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Informntion: <br />Desi3n Flow (gpd) <br />Design Soil Application Ratc(gpdsi)Dispersal <br />Area Required (st) <br />Dispersal Arca Proposed (sf) <br />System Elevation <br />du <br />`D o <br />I C/ 3- v <br />VI, Tank Info <br />Capacity in <br />Total <br />*of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />c <br />Kew Tan"- ExistingTmis <br />u <br />1 C✓ <br />' <br />N :n <br />rn <br />v <br />L• C7 <br />c <br />C <br />Septic or Holding Tani; <br />U <br />17sU <br />Vd . •' . <br />` <br />Dosing Chamber <br />VII. Responslbillty Statement I, the undersigned, assume responsibility for installation of the POWFTS shown on the attached plans. <br />Plum •s Name (Print) <br />Plumber's • aturc <br />MPjMPRS Number <br />Business Phone Number <br />5Z c e_ I- <br />% <br />7i5' 59 -oZo z <br />Plumber's Addrrreess (Strict, City, State, Zip_C`ode) <br />/ ��JJ j� q <br />Z7 � i�� .V V il3Si'{>� i,/�%" 5-1, 1 <br />VIIq. Count- epartment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />s <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />3 7s' <br />IX. Conditions of Approval/Reasons for Disapproval <br />UPROVED <br />Attach to complete plans far the system and submit to the Courtly only on paper not les than 8 t2 s 11 Sri es in <br />AUG 17 1018 <br />SBD-6393 (211/11) <br />BURNETT COUNTY <br />9 <br />