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County <br /> Industry Services Division u✓ yl <br /> IS13 * 1400 E Washington Ave <br /> s $ � Sanitary Permit (to be tilled in 6y Co.) <br /> P.O. Box 7162 <br /> Madison, WI 53707-7162 s � <br /> -. i j <br /> Sanitary Permit Application State Transaction <br /> lNmnnber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Ov~�/ /'rVei-W <br /> is required prior to obtaining a sanitary permit. Note:Application tonns 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 at 6 <br /> purposes i <br /> n accordance with the Privacy Law,s.15.04 i)(m),Stats. <br /> I. Application Information-Please Print All Information �' rC o///'?./1/ <br /> Property Owner's Name Parcel# <br /> 576 od 0000 <br /> Property Owner's Mailing Address Property Location <br /> /GD J" 14 b vv fs (A/4- -7/ <br /> Govt.Lot <br /> City,State `,t� Zip Code -.Ty77 Phone Number y., Section -5" <br /> Lc//Lei A,)"V) rr/a ✓�, e� X17 A" 5.S6S-14 (circle one) <br /> II.Type of Building(check all that apply) Lot# T_ 4-�D N; R fn� E or(r <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms -7 Subdivision Name <br /> Block# <br /> ❑Public/Cormnercial-Describe Use 44 <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ® Town of sGd 7� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> W New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Pennit 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 /> VNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Ivtound<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(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> dao S 6 as (a� ��!• y <br /> VI.Tank Info Capacity in Total I #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> c U in <br /> Septic or Holding Tank <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 MP/MPRS Number Business Phone Number <br /> /214& /4 /61� n � -� dstr�s`i 7 1 S- x6& 4/ �7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J -77(pe) Z ,t,. 3.-J` w e/,s t 1 5'zff s 3 <br /> ,V 111.Coun /Dc artmen Use Only <br /> ttq Approved ❑ Disapproved Pennit Fee Q Date Issued // Issuing A 7iature <br /> /`- 11Owner Given Reason for Denial $ 7S` _7 & ZZ-ICD <br /> Condi/tions of Approval/Reasons for Disapproval tt <br /> UvP�` /O 11�� o�SrO�`�✓'t!a�-ir f/�oN+11 1-f 1-f 5or9/'eate� At# GelZr EC� Q�� <br /> b' <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 inch &i[isife <br /> JUN 2 2 2016 <br /> SBD-6398(R0313) BURNETT COUNTY <br /> ZONING <br />