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BURNETT COUNTY <br />ZONING <br />SBD -6398 (R0313) <br />County <br />Industry Services Division <br />Sanitary Permit Number (to be tilled in by Co.) <br />Uj <br />S�. <br />1400 E Washington g Ave <br />P.O. Box 7162 <br />S A IJ I-- <br />+_ , <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 />41-4 �_ <br />Project Address (if different than mailing address) <br />is required 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 infonnation you provide may be used for secondary <br />d 8 O crt4 <br />purposes in accordance with the Privacy Law, s. 15.04(t)(m), Stats. <br />a,c <br />e <br />I. Application Information —Please Print All Information <br />Property Owner's Name <br />Parcel # <br />} <br />M i k C ✓ t r o t c c <br />0'7 -L)r.W.Z-Iry A, A1-5 <br />Property Location <br />Property Owner's Mailing Address <br />//S-0 3U41, <br />Govt. Lot c <br />y, y, Section <br />City, State <br />Zip Code <br />Phone Number <br />/vlA�f0tn �rT L <br />n301 <br />1 <br />319-360�07cr�v� <br />G (circle one <br />T r d N; R 14 E o� <br />I1. Type of Building (check all that apply) <br />Lot # <br />d <br />Subdivision Name <br />I or 2 Family Dwelling — Number of Bedrooms 3 <br />PAlSCAPS 44AALrt Of <br />Block <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />❑State Owned —Describe Use <br />❑ Village of <br />/ <br />+�Q �'� K 10 h <br />CSM Number <br />Town of 0 <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />[I Replacement System <br />Treatment/Holding Tank Replacement Only <br />[I Other lvloditication to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Pen-nit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />3 Q/Q �^ _ g <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 />yS0 <br />J <br />�S-A,S- <br />exu 4-- <br />:VI. <br />V1.Tank Info <br />Capacity in <br />Total # of <br />Manufacturer <br />v <br />Gallons <br />Gallons Units <br />L o <br />U y <br />New Tanks <br />Existing Tanks <br />o <br />c U n y <br />"c <br />U a <br />Septic or Holding Tank <br />y 0 0 <br />/000 <br />Dosing Chamber <br />d U <br />600 <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 />6-lc k.h <br />�� <br />J)s�-r� <br />7,S_-_ G- �is--7 <br />s <br />Plumber's Address (Street, City, State, Zip Code) <br />1� 7 7& 0 1�4, y <br />VIII.County/De artment Use Only. <br />Approved <br />11 Disapproved <br />Permit Fee <br />p 0 <br />Date Issued <br />Issuing Agent Signature <br />El Owner Given Reason for Denial <br />� ? ` <br />v �j __ <br />7—,10-19 <br />IX. Conditions of Approval/Reasons for Disapproval E C E OVE <br />JUL 06 201 <br />Attach to complete plans for the system and submit to the County only on paper not less thU 8 t/U l l inches in size <br />BURNETT COUNTY <br />ZONING <br />SBD -6398 (R0313) <br />