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Attach to complete plans for the system and submit to the County only on paper not less than i j(Alls% sj i U V C <br />�-•.' JUL 12 2018 <br />SBD -6399-(P, W14 <br />BURNETT COUNTY <br />ZONING <br />Industry Services Division <br />Comity <br />6T <br />1400 E Washington Ave <br />v Xt <br />Sanitary Permit Number (to be filled in by Co.) <br />_ <br />P.O. Box 7162 <br />Madison, Wl 537!17 7162 <br />.� a <br />Smif __ _ Pert A Uc <br />State Transaction ,Number <br />A <br />In accordance with SPS 3$3.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />/" <br />P.r©jecf than mailing address) <br />.is.>equined prig to obtaining a sanitary permit. !Vote: Applicatian farms far state -ov reed_FOWTS arsesubmitted to <br />the DQpartmeFlt cef Sa€city:and;Prfsfcsstonal `Serv,=s; ,ersonal; informatm yo4.prov4de mzy'bc used..for secondary <br />purposes in accordance with the Privacy Law, s. 15.04 1 m-, Stats. <br />�— <br />L A •catwainfoacmutW&-Elxml!rijit U :Inbrmatisn <br />Property Owner's Name ` <br />U <br />P"'wel # ,07-VJ9- �'r y +�7 - 3 • <br />3.4 hE n .J50 t^J <br />,- 0/-000-0%2000 <br />PrIPro erty Owner's Mailing Address <br />A <br />Property Location <br />.3 61 t4-.,.y co.,j+y A <br />Gm. Lot <br />a 3 <br />city, <br />Zip C ede -P <br />eNr <br />,State / <br />A/ 9"Y4, Alt%l Y, Section <br />5>r>oo.✓ E2 tom/ <br />S K CFO <br />le or � <br />T � iV; R - E <br />11. Type of Building (check all that apply,) Lot <br />S+mttivisioe lie <br />Family Dwelling— Numberof Bedrooms <br />2 F : <br />Block <br />" <br /># <br />. C...cw- Describe Use <br />"ity of <br />CSM <br />Mate <br />E+dbw of <br />Number <br />Describe Owned - Desce [ase <br />�pwn SC-0 <br />of <br />III. Type of Permit. (Check only one box on line A. Complete line B if applicable) <br />A.1, <br />ew System <br />e System <br />e. remm.V .Witag Tank )Replacanemt only <br />Modific.o. to Exi tmg sysrerrt (explain) <br />B. <br />E _ <br />" ii Renewal <br />E» <br />it Revision <br />e•' <br />ge of Plumber <br />E" i <br />t TransfertoNew <br />Llm P---s Permit Number and Date LSsued <br />BdoiE'Expimtion <br />Owner <br />�tJrV�. <br />IV. Type of ]?O'Il TS ! ontmtWDeviec(ChcckzHthatVpW <br />on-Pressurized ln-G-ound ped ta-Gromui t-Grade > 24 is of suitable salftl124 in. of suitable sorb, <br />a ec <br />u�oklw4T=k L�lFtser Des—a1.Comp-eat (-gA2m)tme�t IDe+nce (explaan). <br />V. Dis ersal/Treatment Area Information: <br />Deagag Nowt ) <br />0-p Sort A•pplicariC RM(gpdsd)Drsijarsal <br />6Awa '(stj <br />DisPslsale 41 p�-d 1(st) <br />_ <br />Sys(vun Ete`` <br />VL Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Ung <br />w <br />a � <br />d <br />�• <br />New Tanks <br />Existing Tanks <br />y o <br />c� v <br />a <br />C (;5 w 0 <br />(M1. <br />ti <br />Septic or Holding Tank <br />1000 <br />0(> O <br />) <br />1 <br />G f <br />Dosing Chamber <br />VIL Respon&ibility Statement- S, The undersigned, assume sp sib?thy <br />r ingtaittion-oi'the n on 'the attaekee,lflans <br />IF s Name(Priza) <br />lumber's <br />Number <br />Business Phone Number <br />ljq� <br />N R c N <br />S3�� ; <br />7� <br />PlumbaN '5Address <br />( CState,r 1pe)5L( <br />� � <br />VIIEL County rtme"t Use 04y r <br />Pproved <br />Fa <br />A isapproved <br />Peimlt' -ee <br />Date Issued lsSnkng AS=d S. <br />IX. Conditions of Approval/Reasons for Disapproval /�A t / <br />AP?IOVED IisX%v� % .ve �mIle P ftlZ A6a,�a�o,�e�. <br />Attach to complete plans for the system and submit to the County only on paper not less than i j(Alls% sj i U V C <br />�-•.' JUL 12 2018 <br />SBD -6399-(P, W14 <br />BURNETT COUNTY <br />ZONING <br />