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,✓ „�.., Court <br /> ` :; Industry Services Division 1� <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P P.O. Box 7162 6q I i 9/_ <br /> ' L s .j Madison,WI 53707-7162 %-/ T `/� <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 <br /> is required prior to obtaining a sanitary permit. Note:Application fortis 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 y -71 <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. 0 ==JJ <br /> [. Application Information-Please Print All Information W In of ors k <br /> Property Owner's Name Parcel 9 <br /> Jon (�aUvQ oy.ol�f-d-3d-is=o6-sr�r <br /> oQ8- v+dDoo <br /> Propperry Owner's 6 <1`41 Mailing Address Properly Location <br /> 6,o-,dO n 1-?d. Govt.Lot g <br /> City,State Zip Code Phone Number /, /., Section <br /> .J/f Ptn WZ.' SW 87ok le one <br /> [I.Type of Building(check all that apply) Lot# T 3 N; R E <br /> I or 2 Family Dwelling-Number of Bedrooms_ 3 Subdivision Name <br /> Block# <br /> ❑Public/Coirunercial-Describe Use <br /> ❑ City of <br /> CSM Number El Village of <br /> ❑State Owned-Describe Use Y <br /> V �0 I11 p/ _ l/te�< <br /> TOWR(Jf G.t. f's <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y ❑ Replacement System ❑"CreannenUl lording"Conk Replacement Only El 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 Sys tem/Com onent/Device: (Check all that apply) <br /> 9 Non-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> L1.576) 1 . 9- W d C' 17 <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Lnits '� v <br /> a <br /> New Tanks Existing Tanks <br /> c, U rn y rn iC U a <br /> Septic or holding Tank /o S-O <br /> Dosing Chamber <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/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ttftrrVIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Pennit�e Date Issued Issuing Agent Signatu$ 33 Do ,J <br /> ❑ Owner Given Reason for Denial 7-a y- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> DECEWE -n) <br /> Attach to complete plans for the system and submit to the County only on paper not less than A 1rzes in size <br /> APR 2 6 2017 <br /> SBD-6393(R0313) BURNER COUNTY <br /> ZONING <br />