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.•�.y'urts? ., Court <br /> Safety and Buildings Division <br /> %! $Pi 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ��• s <br /> S ..� Madison,WI 53707-7162 5 ��� <br /> irf <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 G Ou v f1 ;41,?w <br /> is required prior to obtaining a sanitary permit. Note:Application fortes 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(1)(m),Stats. �B {lam B/✓ �k�d <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Adv_ <br /> Property Owner's Ma ling Address Property Location <br /> 1157 �1Govt.Lot 2 <br /> City,State - Zip Code Phone Number y,, K, Section <br /> (Circle one) <br /> GvP' CJF T��N; R E.4 <br /> H.Type of Building(check all that apply) Lot# <br /> Ki or 2 Family Dwelling-Number of Bedrooms_. T . Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> V C AV <br /> Town of UAAbt✓ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System f�rlkeplacemenl 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 S stein/Com onent/Device: (Check all that appiv) <br /> igNon-Pressurized In-Ground ❑Pressurized 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.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsi) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y56 . V` goo goy ?v <br /> VL.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o <br /> New Tanks Existing Tanks o u 2 y a <br /> U y Yq <br /> C U rA m CA R 0 r— <br /> Septic or Hotding Tank <br /> Dosing Chamber ••Y tA�J <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pl7C04f-!71;d*nde,-- <br /> s Name PI s ignat� MPiMPRS Number Business Phone Number <br /> 51-f-115-545-02-0Z_ <br /> Plumber's Address(Street,,City,State,Zip Code) <br /> 7_7Z20 _T4rr1,'�../ v we,451,W" <br /> VIII.County/Department Use Only <br /> Approved I ❑Disapproved Permit Fee Date Issued Issuing Agent Signatu <br /> n <br /> ❑Owner Given Reason for Denial ��s• 0�/ 7 ` <br /> IX.Conditions of Approval/Reasous for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x i l i <br /> SBD-6348(R.11/11) "111 <br /> EP09 2016 <br /> 0 <br /> BURNETT COUNTY <br />