Laserfiche WebLink
County <br /> r ;+ Industry Services Division u rvt 1157�4_ <br /> 1400 E Washington Ave <br /> � 9 Sanitary Pe t�Number(to be filled in by Co.) <br /> P �`� P.O. Box 7162 ��/ 7'7 <br /> 3 'fir$ rx� Madison, WI 53707-7162 `7 7 r <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 fors 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 Y6 7 y <br /> urposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. p <br /> I. Application Information-Please Print All Information LGICt to /7pc <br /> Property Qwater's Name Parcel N <br /> o�- <br /> F;/] eJ.t-d-yr-ls-.Ia-s'os- dot <br /> a mar/ m� �� /NrsC - O.I0000 <br /> Property Owner's Mailing Address Property Location <br /> -?11 h.,Y 1, Govt.Lot . <br /> City,State Zip Code Phone Number y,, '/,, Section <br /> 1 �� S4 avr `A tvl- G/A9 (circle ane <br /> 11.Type of Building(check all that apply) Lot i / T y/ N; R IS- E o�V <br /> I or 2 Family Dwelling-Number of Bedrooms 6 Subdivision Name <br /> Block N <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSNI Number ❑ Village of <br /> v-1 ? ao 5 Townof sw.ss <br /> ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ,<New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Pennit Revision List Previous Permit Number and Date Issued <br /> ❑ Change of?lumber ❑Pennit Transfer ro New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> LtNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> I' Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> _?60 1 1 — <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Units <br /> a Y <br /> New Tanks Existing Tanks w U u `u <br /> o = 2 v s <br /> Septic or Holding Tank is O 0 x <br /> Dosing Chamber <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 N1P/MPRS Number Business Phone Number <br /> /C/e, �Ci y 44.4z <br /> Ptumber's Address(Sheet,City,State,Zip Code) <br /> III.CountyfDepartment Use only <br /> Approved ❑ Disapproved Pergmit Fez Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $ `� .�O 7`31 7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> h4 In. aN Daa,� r�CA� Ito = 9�yoo `����� 7coQ,d0 [�Cf�9VE <br /> nn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 US x l inc sin size <br /> BURNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />