Laserfiche WebLink
County <br /> / Industry Services Division e 7`/- <br /> 'Y+' 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ari <br /> Is �t-i P.O. Box 7162 <br /> 5B97c(0 <br /> Madison,WI 53707-7162 <br /> -(t— <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 G O vN y /r o, f w <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Depanment of Safety and Professional Servies. Personal information you provide may be used for secondary La <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. 3 0A I <br /> / (N O Cat^ t y 5 ,„t ? <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel NIS- <br /> 7 <br /> /(o- •s'_s 61 <br /> Sca7rf (,e,ed dtl o7- 03d O 61 X066 <br /> PropertyOwner's Mailing Address Property Location'103(; Meed /?d Govt.Lot <br /> City,State Zip Code Phone Number y,, /., Section -� <br /> k h <br /> SNS3 0 (circle one) <br /> c.r � <br /> Q.Type of Building(check all that apply) f Lot# T 40 N; R /to E or <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms a 3 7 Subdivision Name <br /> Block# STAC6 S Lea <br /> 11Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 21 Town of -5'LV I-SS <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System p y ❑TreannenUl lolling Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> y Replacement System <br /> B. ❑ Permit Renewal El Permit Revision El Chane of Plumber ❑Permit Transfer to New n <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner �i� _ —Q 1 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> o V <br /> Non-Pressunzed In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suilable sell <br /> ❑ holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) - <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> -3 .7 e-I J 9 y3,( 1 9&-. a <br /> VI.Tank Info Capacity in Total #oc Manufacturer u <br /> Gallons Gallons Units U$ H <br /> New Tanks Existing Tanks c v > m <br /> 0 <br /> a V 'vr <br /> Septic or Holding Tank _7J <br /> ^_o 7.3 a '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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ?IG/G /t/ le k7 / dJsss-1 ?/.s�sGG-y�,S'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> >�w, <br /> ,V 111.Count /De artment Use Only <br /> yl Approved ❑ Disapproved gPernit7Fee` 0 V Date Issued Issuing Age Si afire <br /> /1l ❑ Owner Given Reason for Denial / 7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> nD ECEIVE -n-) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 vz 11 in size <br /> JUL 0 7 20% <br /> SBD-6398(R0313) BURNETT COUNTY <br /> ZONING <br />