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Count, <br /> Safety and Buildings Division Btu_I—N 4 <br /> D$ r� 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in by Co) <br /> '� ps Madison,WI 53707-7162 <br /> Sanitary Permit Application Sate TrayaetinmNnmber <br /> In accordance with SPS 383.21(2).W is.Adm_Code,submission of this form to the appropriate governmental unit <br /> z14 44 8� <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 N <br /> ashf��tvs CO•-W353'J4j v7•o3�F- -B /2S�S9 -a2aao <br /> Property Owner's Mailing Address Property Location <br /> ;- 3o a 4f Ziwl-Pwoed Gi��'�• Govt.Lot <br /> City.State Zip Code Phone Number y /,, Section <br /> Gt�PN fS�AY e one <br /> T 37 N, R _Ec <br /> ll.Type of Build ng(check all that apply) Lot 9 <br /> ?�I or 2 Family Dwelling-Number of Bedrooms ' Subdivision Name <br /> Block ubcpezia,4 <br /> � <br /> ❑ Public/Commercial-Describe Use ❑ Cityof <br /> CSNt Number F1 Village of <br /> 11 State Owned-Describe Use <br /> rp 7- <br /> Pr Toon of /[^4 W� GIC <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> 11�New System ❑ Replacement System ❑ TreatmenHoldine Tank Replacement Only ❑ Other Modification on ro 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 System/Com onent/Device: (Check all that apply) <br /> _VNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ .At-Grade ❑ Mound>24 inof suitable soil F Mound<24 in,of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V. Dis ersalrFreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rata(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevation <br /> 30 C J I 300 33 4 96 •99 <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units o _ <br /> New Tanks Hxistine Tanks v " s a _ <br /> Septic or Holding Tank O 7SD <br /> Dosing Chamber �V �d <br /> VII. Responsibility Statement— 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/NIPRS Number Business Phone Number <br /> 1216/c iS fsdG y/f7 <br /> Plumber's Address( neet,City,State,Zip Code) <br /> 77 60 /,/, 3-"C— <br /> VI11.Countv/De artment Use Only <br /> Approved ❑ Disapproved <br /> Permit�Fee Date Issued q� Issuing :Signatur <br /> $ <br /> [I Owner Given Reason for Denial <br /> 1\.Conditions of Approval/Reasons for Disapproval <br /> D CMC <br /> Attach m complete plans for the system and submit to the County onh on paper nat less than 8 Ia x <br /> Juitt <br /> in size <br /> BURNETT COUNTY <br /> SBD-6398(R. 11/11) ZONING <br />