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County ,p <br /> / Safety and Buildings Division Bomete <br /> �j,�p) ®$ �,", 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> t p$ z Madison,WI 53707-7162 <br /> �#a14- � 55g S !l <br /> State Transaction Number JJ <br /> V I <br /> Sanitary Permit Application <br /> In accordance with SPS 383 2](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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Set-vies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stars. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# CO3-4waog <br /> '• 3 <br /> Property Owner's Mailing Address Property Location <br /> Q !' LN Z <br /> Govt.Lot J7 <br /> City,State Zip Code Phone Number y,, 7., Section ZS <br /> W r _d Z� 6157 AZZ ucle onrl��J� <br /> T N, R E mw <br /> 11.Type of Building(check all that apply) Lot# <br /> �1 or 2 Family Dwelling-Number of Bedrooms C Subdivision Name <br /> 8e4 <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 38/097 ❑ Village of /� <br /> Vol. z l � z� 6C&4 <br /> Town of <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ❑ New System a lacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ) <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 a I <br /> lNon-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 /> Design Flow(gpd) I Design Soil plication Rate(gpdst) Dispersal Required(st) Dispersal a Proposed(sf) System evation <br /> VI..Tank Info Capacity in Total d1 #of Manufacturer o �/77yy S <br /> Gallons Gallons Units U $ <br /> New TanksExisting Tanks d o g j �' ro <br /> 2 U v� H rn ii U a <br /> Septic or Holding Tank /ys/1 �- X 1 r' <br /> Dosing Chamber V�'�� I <br /> VI 1.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PZ's Name(Prin Plum Signature MP/MPRS Number Business Phone Number <br /> 40 <br /> � er <br /> Plumber's Address(Street,City,State,Zip C <br /> Z72�DT4�i� �ela�O" li-�✓�v ' <br /> Vlll.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing A gnature <br /> ❑Owner Given Reason for Denial c.��+� f���7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D ��MC� <br /> JUL - 5 201 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/i x 11 inc i e <br /> BURNM COUNW <br /> SBD-6398(R. 11/11) <br /> ZONING <br />