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. � <br />Industry Services Division <br />County <br />3in ✓Vl-C 7`t <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />P.O. Box 7162 <br />P.O. <br />SArt1-18-19 ' <br />,�:, <br />. - <br />Madison, WI 53707-7162 <br />609399 CST- -133 <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 />3 j 6 Q <br />is required prior to obtaining a sanitary permit. Note: Application forms 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 />A 7 y 9'7 b <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />Print <br />I. Application Information — Please All Information <br />Property Owner's Name <br />Parcel # <br />J�•evt l3rnok�5 <br />o�—aaa''d-y0-/`/-33-d-o5+ <br />000 - nii oao <br />Property Owner's Mailing Address <br />Property Location <br />1�/ a NS <br />Govt. Lot <br />y /4, Section 3 3 <br />City, State <br />Zip Code Phone <br />Number <br />�n <br />R 0 G� e � /, / y <br />,S—X*17 /w <br />(circle one) <br />T _� N; R E or67 <br />II. Type of Building (check all that apply) Lot <br /># <br />1 or 2 Family Dwelling — Number of Bedrooms 3 <br />Subdivision Name <br />Block <br /># <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />❑ State Owned — Describe Use CSM <br />❑ Village of <br />Number <br />.� Town of <br />Ill. 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 />El Permit Renewal <br />❑ Permit Revision <br />Change of Plumber ❑ Chance <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 apply) <br />N on -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade Q0 Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ HoldingTank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treat ent Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate( <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (st) System <br />Elevation <br />Ys0 <br />S• 5 <br />W—C, <br />S_o y <br />9 7, / 7 <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />y <br />Gallons <br />Gallons <br />Units <br />5 U <br />New Tanks <br />Existing Tanks <br />a <br />0 <br />Y <br />=2_R <br />u <br />c <br />U cn V, <br />Cn <br />Septic or Holding Tank <br />/D d v <br />Dosing Chamber <br />G0 <br />Goo <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 />Plumber's Address (Street, City, State, Zip Code) <br />of 7 ?G U �� Gr/--. S r�Y �i✓.i S yi 3 <br />Vill. County /De artment Use Only <br />-,Approved <br />El Disapproved <br />Permit Fee <br />Date Issued <br />Issu' g Agent Signature <br />$ ? <br />2_� <br />l <br />I <br />❑ Owner Given Reason For Denial <br />J <br />o� <br />IBC. Conditions of Approval/Reasons for Disapproval <br />� W E <br />SEP 2 6 2018 <br />Attach to complete plans for the system e I on paper not less than <br />8 W x i ches in size <br />SBD-6398 (R0313) <br />Q= <br />BURNETT COUNTY <br />ZONING <br />