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commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Al e n C`� -- <br /> i sco n s i n Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> tDaparta-MIt of Commerce / D / <br /> Sanitary Permit Application State Tmnsactiom Number <br /> In accordance with a.Comm,83.21(2),Wis.Adm.Code,submission of this forth m the appropriate govenunental unit urequired prior to obtaining a sanitary permit Note: Application forma for at POWTS are Projec[Addrwa(if different than mailing address) <br /> submitted to the Department of Commerce. personal information you provide may be used for secondary <br /> ass m accordance with the Riva, Law,s.15.04(1 m),Stats. <br /> L Apelication Information-Please print AR InformatioIZ Cti��,sro /•�� <br /> Properly Owner's Name Parcel# <br /> Ue �/ 3 -/LlO!8 336 a{O4goo(� From / Oe4., 07 ol3d J9/ <br /> Property Owner's Mailing Addteae 6 0,9 MO loco O/3 o eO <br /> P <br /> p Property Location <br /> city, te�e><S6 Govt.Lot Z c <br /> Zip Code Phone Number <br /> .vE W <br /> s v,, se r., Section y eb f er btl y 5489 3 (circle one <br /> IL Type of 1ktBding(check all that aPPIY) Lot# T 3e� N; R /( E or� <br /> 1 or 2 Family Dwelling-Number ofHedrooms 3 ,� Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use <br /> ❑Cityof <br /> 0 State Owned-Describe Use CSM Number 0 village of <br /> V• !Y P Jpl QTown of Wt'en"jIIL Type of Permit: (Check only one box on tine A. Complete tine B if applicable) <br /> A. <br /> . New System 0 Replacement System U Treatment/Ilolding Tank Replacement Only 0 Other Modification m Existing System(explain) <br /> B. ❑Permit Renewal ❑permit Revision UChangeofPlumber Opermit Tmedinto New List Previous Perm it Number and Date Issued <br /> Before Expiration 0"" <br /> TV.T e o(POWTS S tem/Com rnt/Device: Check all that apply) <br /> Non-Pressurized In-Gmond 0 Pressurized laGmuod 0 At-Grade 0 Mound>2,4 in,of suitable soil ❑ Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 tither Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> 7T�khffo <br /> reamlmt Area Information: <br /> d) Design Soil Application Rate(gpdat) Dispersal Area Requred(at) Dispersal Area <br /> ,7 per Proposed(et) System Elevation <br /> 4 3 6 z/eCapacity in Total #ofManufacturer <br /> New TailsGatiom Gallom Unit ExTmdc /000 lCeO S/Lae w �/ <br /> VII•Resportsibility 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/tv1FRS Number Husinesa Phone Number <br /> Rl6& /'/&/0 kIMJ l7� Gae� /�o �Js—�r� pis- S6F-tiir� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -776a /baa,Y rev-e5sl-r, sur SZ/S-93 <br /> VIII.Cour /De artment Use Oil <br /> Approved ❑Disapproved Permit Fee Date Issued Issuin Signature <br /> a {M 4 <br /> ❑Owner Given Reawn for Denial `�W� /4 M a oy <br /> UL Conditions of ApprwaUReasons for Disapproval <br /> Attach to mmpkte plans far the SYmm and submit to the County only an papo•ml led tWo S finrSrs <br /> SBD-6398(R.01/07)Valid tinu01/09 BURNETT COUNTY <br /> ZONING <br />