Laserfiche WebLink
rte. '"'az.7�"; County <br /> 4' `•-;\ Industry Services Division 0µN p e <br /> j f 1. D� "'. 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> " O if:I P.O. Box 7162 <br /> �= t ; P "-10--7 <br /> g f% Madison, WI 53707-7162 2 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adrn.Code,submission of this form to the appropriate governmental unit c023429 <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 Servies. Personal information you provide may be used for secondary oi If8A8 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information 6,41,4,9 e_ Ga n e. MA&(/' <br /> Property Owner's Name Parcel# 33-S- az <br /> 07- orb-a-39-./4 <br /> bre Yid A fpm C.S/an a /44(-11 Lech /140,74,, A y4- 0J.0 O o0 <br /> PropertyOwner's Mailing Address Property Location <br /> )4 57 57 M a ry t4.A d f/ v e G--=, Lot <br /> City,State Zip Code Phone Number , <br /> /, /, Section 33 <br /> .. t. FA I ft' N Sir(i 9 7/s=3 09 9A 89 (circle one) <br /> T 39 N; R ,/ Eor® <br /> IL Type of Building(check all that apply) Lot# <br /> 7I or 2 Family Dwelling—Number of Bedrooms A Subdivision Name <br /> B lock# <br /> ❑Public/Comunercial—Describe Use ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number El Village of <br /> Town of /✓l e-c n s in <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' <br /> ❑ New System X 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 /> 9'Non Pressurized In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ F[aldm>Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V:Dispersal/Treatment Area Information: <br /> Design Flo*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> JJ 6. I <br /> 00 600 93. 3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units B _ <br /> ` O U <br /> New Tanks 5. <br /> Existing Tanks � o � � ��, � � <br /> c, U cn y rn ii C7 a. <br /> Septic or Holding Tank 5-- 7... 0 / W l rf ev X <br /> Dosing Chamber.. J / • ; :)1 <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWYS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature� // MP/MPRS Number Business Phone Number <br /> /2 /6 /`7'/o y /c 1 t S /�=,..d .s// c_ A'rg`57 745---r -%" <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,1477Go „r,,,,, 3.s' Lr' 4 c - 1,V7.---,S—`/853 <br /> VIII.County/Department Use Only <br /> \pproved ❑ Disapproved Permit Fee O Dat [ssu mg gent Signature <br /> ❑ Owner Given Reason for Denial ,34•o 5 (y ito�o <br /> IX.Conditions of Approval/Reasons for Disapproval C IE O R n IE <br /> --Sbsfa t 476414 rort MAO Iva at or amt 13.2i�� v <br /> wut�,st b6 Fvom well. <br /> MAY 1 3 2020 JI <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 la z inc in size ....../ <br /> Burnett County <br /> SBD-6393(R0313) Land Services Department <br /> All J.�i of in n s//n <br />