Laserfiche WebLink
County <br /> { : .•. „� Industry Services Division <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> . �� <br /> ' 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 govetmnental 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(I)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> a-)—aaB-J-ya-lY 1y-soS ooy <br /> c i�,pov <br /> Property Owner's MvIailing Address Property Location <br /> )� f`O o6te-4s /?d' Govt.Lot <br /> City,State Zip Code Phone Number %, %, Section <br /> S goner �jcucleone) <br /> I1.'type of Building(check all that apply) Lot# T C/o N; R / E or� <br /> I or 2 Family Dwelling—Number of Bedrooms G�rl�e w l�0 �+h Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> ® Town of SC o 7r <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System <br /> y ep y ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.i 'e of POWTS System/Component/Device: (Check all that apply) <br /> Nona'res�s`uiized In-Ground ❑Pressurized tn-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Eialdtn3Tank ❑Other Dispersal Component(explain) <br /> ) El Pretreatment.Device(explain) <br /> V Dts 'oral/Treatment Area Information: <br /> Design F16w(gpd) Design Soil Application Rate(gpd4 Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks w c <br /> C. <br /> 0 Cn � rn ri C7 a <br /> Septic or Holding Tank <br /> Dosing Chamber.. t a <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the PObVTS shown on the attached plans. <br /> Plumber's <br /> Name(Print) <br /> Plumber's Signature MP/MPRS Number Business Phone Number <br /> / f c /c <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issuerdl Issuing Agent Signature _ <br /> ❑ Owner Given Reason for Denial $3 S 2 /' Z I �• icy'�`�Lr�— <br /> IX.Conditions of Approval/Reasons for Disapproval $ oZ`J <br /> PE � pC 1odAttach to complete plans for the system and submit to the County only on paper not less than 8 a/2 s II inc <br /> SBD-6398(R0313) Burnett County <br /> Land Services Dapa;ittment <br />