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Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2Q ii i es in size I L j <br />BURNETT COUNTY <br />ZONING <br />SBD -6393 (80313) <br />Iq_ <br />Industry Services Division <br />County <br />;t ; �3S <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Sanitary Permit Nu er (to be tilled in by Co.) <br />l <br />S <br />A <br />VJ <br />, ,� <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />StateTransactionNumber <br />N A <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate pvermnental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary pennit. 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. 15.04(1)(m), Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # _ M <br />J e ifc b Gr~ �tivt b e s <br />_031A06 <br />Property Owner's Mailing Address <br />Property Location <br />/l 7 7 CO 1?W <br />Govt. Lot 11 <br />/, Section / q <br />City, State <br />ip Code <br />Phone Number <br />S moti-er 4415— <br />708-3-7Y- <br />(circle one <br />T �O N; R E c <br />Il. Type of Building (cheek all that apply) <br />Lot # <br />Subdivision Name <br />® I or 2 Family Dwelling - Number of Bedrooms J <br />3 <br />Block # <br />❑ Public/Conunercial -Describe Use <br />❑ City of <br />❑ State Owned- Describe Use <br />❑ Village of <br />CSM Number <br />V )to ? �� / <br />Town of X<.0 <br />I1I. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />XReplacernent System <br />❑ Treatment/Holding Tank Replacement Only <br />El Other Nloditication to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Pennit Revision <br />❑ Change of Plumber❑ <br />Permit 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 appl ) <br />Dion -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) <br />System Elevation <br />7.f-0 <br />.6- <br />/_5-0 v <br />S.r. $_ <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />Gallons <br />Gallons <br />Units a <br />UB <br />New Tanks <br />Existing Tanks <br />0 v 4 <br />Z <br />Na <br />c. <br />U CZ <br />Septic or Holding Tank <br />/ 8� . <br />isvjr <br />Dosing Chamber <br />W-0 <br />ly- <br />i <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />NIP/MPRs Number <br />Business Phone Number <br />/T/ e- le- �a le,N -1 <br />Plumber's Address (Street, City, State, Zip Code) <br />VIII. Coun [Department se Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />7 b D <br />$ 75- <br />Date Issued <br />/ <br />Issuing Agent Signatur <br />11J Owner Given Reason for Denial <br />IX. Conditions of Approval/Reasons for Disapproval <br />c��o�� <br />PPROVED D <br />15 20tR <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2Q ii i es in size I L j <br />BURNETT COUNTY <br />ZONING <br />SBD -6393 (80313) <br />Iq_ <br />