Laserfiche WebLink
/ iaarirF;�r County <br /> Industry Services Division ►�julll�l',�'� <br /> �8 1400 E Washington Ave <br /> P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> �vsnn:rj <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 governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information i <br /> Propert Owner's Name Parcel# j1�•DOS'Z' 'ly's �' 008- <br /> �J . o+y000 iac ff ,29/Property Owner's Mailing Address Property Location <br /> �� A� A <br /> .l_ _ Govt.Lot Set 3 F1. Gc-) 'A <br /> City,State Zip Code Phone Number ''/., '/., Section 2 <br /> 1 �?/v (circle o ) <br /> J �7 T�� N R 'c1 EotJ <br /> II.Type of Building(check all that apply) Lot# <br /> Q 1 or 2 Family Dwelling-Number of Bedrooms c, ✓l,-N {% Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑State Owned-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) t <br /> A. ❑ New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑ Non-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 /> D--',n Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 61 Rate(gpdso <br /> VI.Tank Info Capacity in <br /> Gallons Total #of 2 <br /> Gallons Units Manufacturer <br /> C ; Y <br /> New Tanks Existing Tanks a U <br /> Septic or Holding Tank Q t7 l �,�/ ¢ / ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb is Signature MP/MPRS Number Business Phone Number <br /> zz,� a 71s- 6//s=02y� <br /> Plumber's Address(Street,City,State,Zip ode) <br /> w 43 Z, -Vic,/�& <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee DO Date sued I ui gent Si ture <br /> ❑ Owner Given Reason for Denial $ 3�• /` �J tom �4_ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> PPROVED # �N.�c�.-t- ,fit����TS ��� D <br /> Q S+ttr W 1�d5 Wt�'jtiK on.t. Week d'F iW�a►�L• ,• ) ,��.. <br /> Attach to c plete plans for the system and submit to the County only on paper not less than S 1/2 x in s in size <br /> Burnett County <br /> SBD-6398(R03/14) Land Services Department <br />