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ON COMPUTER/SCANNED <br /> commercemi.gov Safety and Buildings Division County <br /> a 201 W.Washington Ave.,P.O.Box 7162 Q u r N e 7� <br /> i sco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce 41 �,Q , <br /> Sanitary Permit Application State Transaction lqQ <br /> Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental `a' <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. 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 Parcel# <br /> f remh ee ka 0 3,� - S- 0_4 odO <br /> Property Owner's Mailing Address Property Location <br /> A``/ Rd Govt.Lot <br /> City,State Zip Code Phone Number s 'Vti N� %, Section�s <br /> �$ �yj�/ r-1S1 -� �s/' �8/ C�a7� (circle one <br /> °� �J T i/ N; R&Ec� <br /> IL Type of Building(check all that apply) Lot# I <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms 1� Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑ ❑State Owned-Describe Use CSM Number Village of <br /> V a I� P. <br /> I <br /> LI Town of jr L✓t f_Jr <br /> IIL 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 S stem/Com onent/Device: Check all that apply) <br /> Z 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.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application RaWgpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 . 7 L/0t 9 Z13d qd. e <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units r' <br /> a <br /> New Tanks Existing Tanks w a b °° y <br /> 0 <br /> d+U in en w" C7 a <br /> Septic or Holding Tank <br /> Dosing Chamber O �/ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rle_ G � <br /> Plumber's Address(Street,City,State,Zip Code) <br /> o� 776a rG w 3S Gvedsfr.� w�5�8�3 <br /> WApp <br /> un /De artment Use Onled ❑Disapproved aermit Fee Date Issued Issuing Signature <br /> ❑Owner Given Reason for Denial � 3V 07 fiw <br /> IX.Conditions of Approval/Reasons for Disapproval aL6nm <br /> FS <br /> (f L <br /> i <br /> Attach to complete plans for the system and submit to the County only on paper 1 than 81* itt s Goo <br /> SBD-6398(R.01/07)Valid thru 01/09 BURNETT COUNTY <br /> ZONING <br />