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Count <br /> Industry Services Division a rN-4 11f <br /> D 1400 E Washington Ave SanitaryQPermit Numrber Ltto be tilled in by Co.) <br /> $ SPS P.D. Box 7162 5508 <br /> $ a 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 governmental 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 he used for secondary f pr( <br /> mi-poses in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> 1. Application Information—Please Print All Information Ind s� <br /> Property Owner's Name 07-reel"0""'4 <br /> Property Owner's Mailing Address Property Location <br /> .5­/0 s, /l r r e✓ ✓5e• Govt.Lot--f— <br /> City, <br /> f-City,State Zip Code Phone Number y, '/., Section <br /> d 417 7/�- d 61K_ '7/7 (circle one) <br /> ��•f C v$6 n p T �iW N; R /(v E ordP <br /> Il.Type of Building(check all that apply) Lot# <br /> Subdivision Name <br /> I or 2 Family Dwelling-Number of Bedrooms <br /> Block# <br /> ❑Public/Commercial-Describe Use _ ❑ City of <br /> CSM Number El Village of <br /> ❑State Owned-Describe Use <br /> �] Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ❑ New System ,gReplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. n Permit Renewal ❑ Permit Revision ❑ Change of Plmnber ❑Permit Transfer to New List 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 ❑ 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 Applicati n Rate(gpdsf) Dispersal Arca Required(st) Dispersal Area Proposed(st) System Elevation <br /> 4-.1 (r</3 4�48 13.0 <br /> VI.Tank Info Capacity in I otal #of Manufacturer <br /> Gallons Gallons Units s v <br /> New Tanks Existing Tanks $ a <br /> cz U v, y <br /> Septic or Holding Tank /0" /mOs <br /> Dosing Chamber LDS GOI� <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 MP/MPRS Number Business Phone Number <br /> /Z.G/� f/o /Cr _J / .CJS*-S^/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 17 74 O IZ,.o. -..f W-s�S{ri b✓.a j'Y8S? <br /> VIIL Count /DeI artment Use Only <br /> Approved El Disapproved $ennit Fee <br /> R. sOO Date Issued Issuing Agent ature <br /> - -�a-i�" <br /> C] owner Given Reason for Denial 37 <br /> Xe�pu,� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> P ECEIVE <br /> 0t w Attach to complete plans for the system and submit to the County only on paper not less than S 17 lin s in� 10 <br /> 2015 <br /> BURNEIT COUNTY <br /> SBD-6398(R0313) ZONING <br />