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r, 'rt County'� <br /> /e v;, Industry Services Division ;�u r n <br /> 11 p ,•:, 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ' $p 1<i P.O. Box 7162 <br /> �° S � ' Madison, WI 537 0 7-71 62 <br /> "rt"g�rrUt:y <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 govermnental unit 9 q l�_58"j� <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 <br /> purposes m accordance with the Privacy Law,s. 15.04(I)(m),Slats. <br /> 1. Application Information-Please Print All Information m �/ <br /> PTonerty Owner's Narne Parcel# C7-04,-�?-Q <br /> Property Owner's Mailing Address Property Location <br /> //6 fo `%p. xGe Govt.Lot <br /> City,State Zip Code Phone Number Ste y, NW y,, Section -7 <br /> 6 r.^'ft6kv 1�,1� SY FAY -71S- 4$9•• 30133 (circle one - <br /> �/ T 38or� <br /> 11.Type of Building(check all that apply) Lot# <br /> Of 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block 4 <br /> ❑Public/Corrunercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use C'SV Number ❑ Village of D <br /> +Lil Town of WoOa tvKr <br /> I <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ Treatment/Holding Tank Re <br /> ❑ New System �Replacement System placement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber 1 ❑Permit Transfer to New st Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 3 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> -,lSD _9 4is-0 ,S'o y /o/. l <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o Y ro a <br /> c U .� yr i,_U ti <br /> Septic or Ilolding Tank /Q s!U �OBO <br /> Dosing Chamher I Da <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 NIP./NIPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d 776e ,d..... . �Rs bV-66s?4e-, SySS3 <br /> III.Coun /De artment Use Only <br /> ❑ Disapproved Permit Fee Dale Issued Issuing Agent Si <br /> Approved gma re <br /> ❑ Owner Given Reason for Denial S Y 7 'l 9' -951^ 7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> nD ECEIVE <br /> nn . <br /> Attach to complete plans for the system and submit to the County only on paper not less than 31/2 x V <br /> inc It in sae <br /> BURNETT COUNTY <br /> SBD-6398(R0313) <br /> ZONING <br />