Laserfiche WebLink
--.="4*z k\ County <br /> /:itTA '4%.\ Industry Services Division L5LArn.eit <br /> y ,' _{ 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co) <br /> ui ' '4' ' P.O. Box 7162 c�t <br /> I'% ' ray Madison, WI 53707-7162 aPJ -7Z <br /> ,1 x. 095� <br /> �'x,-,- — —22 ] _ <br /> State Transaction'Number <br /> Sanitary Peniiit Application <br /> [n accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental 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 be used for secondary '7(y e{ <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. �- 2 <br /> I. Application Information—Please Print All Information r�"t� 'Pie/ <br /> Property Owner's Name Parcel# S,S <br /> Property Owner's Mailing Address Property Location 1 - W7 <br /> Y&0$ Atver VICw L4' <br /> Govt.Lot <br /> City,State Zip Code Phone Number y %, Section �e <br /> r l N , 1 t t•I circle one <br /> n S `/ T y O N; R /� E or) <br /> II.Type of Building(check all that apply) Lot# <br /> fii II or2 Family Dwelling—Number of Bedrooms .1 // Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use <br /> 01 ❑ City of <br /> ❑State Owned—Describe Use CSM Number p Village of <br /> 1FJ Town of Q'k/and. . . <br /> III.'Type of Permit: (Check only one box on line A. Complete line B if applicable) • <br /> A. New System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to System(explain) <br /> y ElReplacement System p Existing Y ( P ) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber CIPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTSSystem/Component/Device: (Check all that apply) <br /> K`Non Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ IigldtnyTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dispersal/"Treatment Area Information: <br /> DesigiFFld*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 3c0 . 7 40 7 4/.5 o qa•.2 <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units a - o 0 <br /> New Tanks Existing Tanks .3 o v 2 42 <br /> n,U cn v, rn w U tn. <br /> Septic or Holding Tank • e <br /> Dosing Chamber- <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> A.L5-2s-/ 7f_ =!�6 —9/.5-7 <br /> Plumber's Address(Street,City,State,Zip Code) ,, ` <br /> I 7 760 ,L y 3.5' 14/-r she. .5-lee 73 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued I suing A ent Siana a _ <br /> Approved ❑ Disapproved �����_ 6/823 <br /> �� .y❑ Owner Given Reason for Denial /('// tl _ <br /> IX.Conditions of Approval/Reas ns for Disapproval p 7 LI V E l I� <br /> / <br /> ill MAY 2 4 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Us a 11 inches is size Burnett County <br /> Land Services Department <br /> 11375 Cl&ec k. #7SO341 <br /> SRII_F19Q/Pm 1 z) <br />