Laserfiche WebLink
,, Industry Services Division County ,) <br /> `' 1400 E Washington Ave Ll rive <br /> ® P.O.Box 7162 U <br /> i=I . S' Sanitary Permit Number(to be filled in by Co.) <br /> \;.', S Madison,WI 53707-7162 SAN-.ZD—.15-i! <br /> ;\z; 41, c$1 a - 0'4 <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 6:0128Number <br /> oO <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 Services.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 'l Parcel# <br /> �C e is N '7/oke`, O7-o5?-2-4/-6-48-S/S-dy 3-oi9ite <br /> Property Owner's Mailing Address Property Location 0 Z2 595 <br /> P.a,&,1 7Z Govt.Lot (+��jr <br /> City,State //�� r�r� LZippCode Phone Number %,, V. Section �O <br /> �`7uey N� 68336 If42-y/6 rvyoS L,l /(c lEonW <br /> II.Type of Building(check all that apply) Lot# T N; R <br /> or I or 2 Family Dwelling-Number of Bedrooms Z ?d- Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> lir Town of 5(,.s1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber List Previous Permit Number and Date Issued <br /> ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> erNon-Pressurized In-Ground 0 Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding lards 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 . 7 yZ, I/le cm o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Li <br /> Gallons Gallons Units o v <br /> New Tanks Existing Tanks g v y 2 a <br /> a. v -eh- „ yr ii. 3 a <br /> Septic or Holding Tank 6'00 &x j. _ �-iPt1/4) ‘/ <br /> _ <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) Plumber' ignature MP/MPRS Number Business Phone Number <br /> . TI�Q � ��� a%/9sZ/ 7/5--SO-62.c2 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 668/ �vy w L le /2/ kJe6LA. 5'/69 3 <br /> VIII.County/Department Use Only <br /> Permit Fee Dat Issue suing ent Sipa e <br /> earApproved 0 Disapproved S rj4 t <br /> 0 Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> w Well MUu$t be, *ft row drA6treeice. <br /> d DeaivAciti ikkust be /w<<. (.1.4. 90 a9 $ 4 <br /> W potwart trach -111 cress DraiKfra. iii CPC 0 d k i p <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 it hes in size <br /> 1 <br /> JUL232020 <br /> SBD-6398(R.08/14) <br /> Burnett County <br /> Land Services Department <br />