Laserfiche WebLink
County <br /> Industry Services Division i3wr9% 'e.�/' <br /> i 1400 E Washington Ave <br /> � P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> , — <br /> r�, Madison, VVI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govem nental unit _ <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary d j <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats.I. Application Information-Please Print All Information le, D-eV'I.s G/e- /70 <br /> Property Owner's Name Parcel#L11V,C- A?c COO ! 1390 <br /> {(nB <br /> Property Owner's Mailing Address Property Location <br /> 73 y'1 Q✓ �J 4/4 Govt.Lot t� <br /> City,State Zip Code Phone Number y /, Section <br /> We b.s fie✓ y r .5�S c!3 T 4/0 N, R AlE one <br /> 11.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms Ot Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSNI Number Map /"71 ❑ Village of p <br /> V, I ? 1 7) Town of e <br /> III.'Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑ -tvon-Pressurized In-Ground ❑ Pressurized In-Ground 5d At Grade ❑ lvlound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holdin Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design FIow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> 300 7 <br /> VI.'Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units o <br /> ate.. Vi <br /> New Tanks Existing Tanks <br /> 0 <br /> C U cis h t%U C?. <br /> Septic or Holding Tank d e .0 7-1--0 tow It S-e#- <br /> Dosing Chamber. <br /> -CSYr � <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POtiWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br /> /?fole a C /21 dose / 7i,$--8Gb-y15-7 <br /> Plumber's Address(Street,'City,State,Zip Code) <br /> ol 77 0 el 3s— cv w,r S-V 8 9 3 <br /> VIII.Court /De artment Use Only <br /> Pennit Fee Date Issued Issuing Agenk Signat4r4 <br /> 11 Approved El Disapproved <br /> ❑ Owner Given Reason for Denial $✓ / <br /> IX.Conditions of A roval/Reasons 's for Da al rov ( O <br /> PP PD p /l��¢/' Ce4,A / cl/, ffns <br /> �- C E � V LE <br /> Attach to complete plans for the sys nd subm't to t/he ounty ly on p of less than 8 1/3 x 11 inc <br /> / ✓��< BURNETT COUNTY <br /> /S-��5, <br /> SBD-6393(R0313) ZONING <br />