Laserfiche WebLink
-',.;'x' zi4 .1 County <br /> 4�,' . 'J Industry Services Division L) ✓in e it- <br /> !II <br /> � iCyx <br /> f`. .7t 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> '., 1 p 1 P.O. Box 7162 SAN— .2.D <br /> e i � rg i Madison, WI 53707-7162 G no q <br /> Sanitary Permit Application <br /> StateTransaactionNum�b11�.1jer <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (o23 <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 grpDO <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information-Please Print All Information ?Ark- L� <br /> �r <br /> Property Owner's Name Parcel# ,S"'/5--34o <br /> Gscry �a`✓lG1hS 07-0,i0.�.."74" 6-(9— <br /> — /053t e a <br /> Property Owner's Mailing Address Property Location li348 <br /> Soo( Ra i< 5* Govt.Lot 44 <br /> City,State Zip Code Phone Number 'h, 'A, Section / <br /> ()A h(b,w fr y // 3 yd3e (circle one <br /> II.Type of Building(check all that apply) Lot# T 90 N; R /6 E of <br /> 0 I or 2 Family Dwelling-Number of Bedrooms ) Subdivision Name <br /> Block# <br /> ❑Public/Conunercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> j' Town of (2G(61a ei a( <br /> M.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ini New System 0 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 /> xt Non P,essurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑•Holden Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Disperill/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a :-'1' a <br /> New Tanks Existing Tanks o v 2 3 a Sg <br /> c,U cn . rn u-. V a. <br /> Septic or Holding Tank /0,0 /BD ....5.2%0w Jt <br /> O / 0 <br /> Dosing Chamber.. ! X .,1 <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 j NIP/MPRs Number Business Phone Number <br /> RI GIG <br /> o , kik, 5 /a.4.4/a.4.4.,/// - "7/.S= "- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> of 776 e, //,...y 3f Lt»e6 r• <br /> t 1/_.-/------- <br /> ..5-5'487_ <br /> VIII.County/Department Use Only <br /> proved ❑ Disapproved Permit Fee Date Issue ' , gentigna e <br /> 0 Owner Given Reason for Denial $ 3.4. 00 ,AGr 2A0Z0 <br /> IX.Conditions of Approval/Reasons for Disapproval ffECIEOVE .--1 <br /> (t/J <br /> ii ma woo be :ff fieviA 'Dramk.1614 1 . <br /> IdDet;,I cki 'two kot level. JUN 1 9 2020 JA <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 s II itches in•ze <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R0313) ri - h"iA i a t 04114" <br />