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QN COMPUTER/SCANNED <br />�,Aeia-�,r0. • <br />trq?' <br />"�;,.: <br />Industry Services Division <br />County <br />%3r~rn� <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />P.O. Box 7162 <br />SAN_ IS- 03 <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 />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary pen -nit. 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 />9993 <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />of <br />Ih er✓a 'Jq vn /� <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />oParcel� 3� _ Y I_ - 35-- 1 iy,l -O oO <br />-011ooc <br />j�atwl a✓� <br />Property Owner's Mailing Address <br />Property Location <br />1.6 rly 1 `1 tti r?ve <br />Govt. Lot <br />ALAL , , <br />/, /., Section 3 s <br />City, State <br />Zip Code <br />Phone Number <br />/1/. 5 �G+w� /•y') N. <br />$-f/O� <br />(old' d �i' 73d 6 <br />circle one <br />T L// N; R /� E ot�J <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />I or 2 Family Dwelling - Number of Bedrooms <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />EJ State Owned -Describe Use <br />❑ Village of <br />CSM Number <br />V 9 P <br />Town of Stvl SS <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 />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />C,, 1Y �� ys/ 9-3—?X <br />IV. Type of POWTS System/Component/Device: (Check all that apply) <br />U Non Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound> 24 in. of suitable soil ❑ Mound <24 in. of suitable soil <br />❑ HoldinoTank ❑ 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 />6003- <br />I ADO <br />/J�00 <br />9d.s fo 9A• -7 <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units <br />o <br />U r <br />New Tanks <br />Existing Tanks <br />o v <br />y <br />c <br />U Cn h <br />rn <br />Septic or Holding Tank <br />% 0 <br />1100 <br />Dosing Chamber <br />a <br />iz <br />900 <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 />� <br />NIP/MPRS Number <br />Business Phone Number <br />`Lf4 <br />z/GlG I/d k1 3 <br />� I`t <br />��5��1 <br />7/r 7 <br />Plumber's Address (Street, City, State, Zip Code) <br />7760 3.r (it/ -o =s �,rr w� 5-YPI-7 <br />VIII. County/De artment Use Only <br />Approved <br />11 Disapproved <br />Permit Fee O <br />D <br />Date Issued <br />Issuing Age Si atur <br />El <br />$ 376'_-g-lS <br />Owner Given Reason for Denial <br />IX. Conditions of Approval/Reasons for Disapproval Et'E I V E <br />nnFEB <br />0 6 2018 <br />Attach to complete plans for the system and submit to the County only on paper not less than S 1/2. 11 in"es in size LJ <br />BURNETT COUNTY <br />ZONING <br />SBD -6398 (R0313) <br />