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County- <br /> Industry Services Division <br /> • p 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ° .\$P$ I-I P.O.BOX 7162 sgOdos- <br /> i Madison,WI 53707-7162 <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 <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 <br /> purposes in accordance with the Privacy Law,s.15.04(l m,Stats. <br /> L Application Information-Please Print All Information <br /> Property Owner'si�ame( '_Iy" Parcel# <br /> If-t b VCt7f`1 �Cw(Nyt 1`fJ On 07 of Y .2 38oa 000 o /1-10c <br /> Property Owner's Mailing Address Property Location: <br /> 3 i ,V y o Govt.Lot / _ <br /> City,State A, Zip code Phone Number J �y,• AJ l.y y,, Section�� <br /> r-.n+to�� ( l J�Iv SSDOC1 Iso p�f�o� �L( � cnrcleone <br /> H.Type of Building(check all that apply) / Lot# T�N; R�E o" <br /> VQ for 2 Family Dwelling-Number of Bedrooms 7 Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use <br /> ❑ City of <br /> CSM <br /> ❑ State Owned-Describe Use Number ❑ Village of <br /> J&Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Pew System ❑ Replacement System ❑Treatment/Holding Tank ReplacementOnly ❑Other Modification toExisting System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change ofPlumber ❑Permit TransfertoNew List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> EFF FILTER MFG: LEACHING CHAMBER MFG: <br /> IV.Type of PORTS S stem/Com nenUDevice: Check all that apply) <br /> ❑Non-Pressurized In-Ground PtPressurized 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) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �� i .� Z) a 000 q7,3 R4, 7S- <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o u 2 <br /> 0. U in V ii 5 a. <br /> Septic or Holding Tank 100 O <br /> Dosing Chamber 600 <br /> VII.Responsibility Statement-I,the undersigned,assu res ns' i'ty for installation of the POWTSowa on the attached plans. <br /> Plum r'sName(Pri Plumber's i e RS Number Business Phone Number <br /> ( v g_c FI 1 3w ?Is wi6 r s ala <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9d t & <br /> VIII.Couny!?!partmerit Use O <br /> Approved D Disapproved Pijmm Fee Date Issued Issui Ag t Si titre <br /> Owner Given Reason for Denial 3 7S 4'1S <br /> IX.Conditions of ApprovalfReasons for Disapproval <br /> MR <br /> Attach to complete plans for the system and su 't h t S I/2 s I I inches in size <br /> Nov 12 2015 <br /> SBD-6398(110313) n <br /> BURNETT COUNTY <br /> ZONING <br />