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: ttan, to cumpieEe puns for me system arm sunmtt to Elle k-ounty only on paper not less than 81124 11 itM:ttes in size L J <br />BURNETT COUNTY <br />ZONING <br />SBD -6393 (110313) <br />Industry Services Division <br />County <br />/ 1A V h 1W <br />SPS ` <br />1400 E Washington Ave <br />9 <br />Sanitary Permit Number (to be tilled in by Co.) <br />.; <br />P.O. Box 7162 <br />5Ar - 13—(D <br />� - <br />Madison, WI 53707-7162 <br />�a7i9�Q CS?- /g—ql <br />Sanitary Permit Application <br />State Transaction Number <br />J <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate goverruriental unit <br />is required prior to obtaining a sanitary permit. Note: Application fors 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 />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 />Pnrt'Pl # <br />Property Owner's Mailing Address <br />Property Location <br />k,007 f- /6 w a -e ✓ /� /` <br />Govt. Lot y <br />y, /, Section 3 <br />City, State <br />Zip Code <br />Phone Number <br />:/G� N 6j (A rrI <br />(circle one <br />T y� N; R �b E a� <br />11. Type of Building apply) <br />yp g (check all that a 1 <br />Lot # <br />❑ I or 2 Family Dwelling — Number of Bedrooms <br />1 <br />Subdivision Name <br />Q <br />_Jt h$2Y�S, R\e,`-Clew P0.`(,K <br />IU <br />Block <br />B <br />❑ Public/Conunercial —Describe Use <br />❑ City of <br />❑State Owned —Describe Use <br />❑ Village of <br />CSM Number <br />JO Town of <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Pen -nit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Pennit Number and Date Issued <br />Before Expiration <br />Owner <br />33977 <br />IV. Type of POWTS S stem/Com onent/Device: (Check all that apply) <br />FNon 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 />3v� <br />.% <br />�3a <br />780.oa <br />5y.a d <br />V1. 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 />o 2 <br />� <br />=2 R <br />e <br />aU <br />in y <br />n <br />V <br />a <br />Septic or Holding Tankv� <br />J <br />/ <br />Dosing Chamber <br />(, <br />1 <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 <br />NIP/MPRS Number <br />Business Phone Number <br />fa <br />/sSSignature f� <br />Plumber's Address (Street, City, State, Zip Code) <br />o� 7 > t o 1 .�s 1/!/'� s rbc✓ 1.v� .5—� �S 3 <br />V Il. Coun /De artment Use Only <br />pproved <br />❑ Disapproved <br />PermitFeenate Ilss%ued <br />Issuin gent Sid re <br />ElOwner Given Reason for Denial <br />�� <br />S 3:L (0 i v <br />IX. Conditions of Approval/Reasons for Disapproval <br />E C`;" E <br />nn <br />MAY 3 0 2018 <br />: ttan, to cumpieEe puns for me system arm sunmtt to Elle k-ounty only on paper not less than 81124 11 itM:ttes in size L J <br />BURNETT COUNTY <br />ZONING <br />SBD -6393 (110313) <br />