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County <br /> Safety and Buildings Division ('/V <br /> �S xi 241 W.Washington Ave.,P.Q.Box 7162 samtars petn,f Zto be filial in by Co.) <br /> _Y PS of Madison,WI 53707--7162 _yJn,� DTI J <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Nis.Adm.Code,submission of this form to the appropriate governmental trait <br /> is required prior to obtaining a sanitary permit. Note:Application fortes for state-owned POD TS are submitted to Pmject 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(1)(m),Slats. <br /> t. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> 0,%je&y..rJ Zt`t714r!-,ma.J _ Oay-o7-T �S-Aa6�o33�v <br /> Property Owner's Mailing Address Property Location <br /> Z �r rwa urVV4 GovL Lot <br /> City,State Zip Code Phone Number V,, 14, Section 7 <br /> pQ/rbv� W ` 5'YB3b etrele o r T ��TI; R E <br /> II.Type of Building(check all that apply) Lot# <br /> Y'I or 2 Family Dwelling—Number of Bedrooms Z 'f�6 Subdivision Name <br /> S <br /> Block# I-14 <br /> (1 <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use 7Number ❑Village of —� <br /> Town of !�o 0, <br /> III.Type of Permit: (Check only one box on line A. Complete tine B if applicable) <br /> A. <br /> ❑ New System fj7Rep{acement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to Nety List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com neudDevice: (Check all that apply) <br /> IWNon-PressurizedIn-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.ofsuitablesoil 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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sfj System Elevation <br /> 340 • 5 400 (9416 9"1./ <br /> V L Tank Info Capacity in Total #of Manufaetwer <br /> Gallons Gallons Units ,o <br /> New Tanks Existing Tanks o u a o <br /> Septic or Holding Tank O / �,Cn <br /> Dosing Chamber <br /> VII.Responsibility Statement—I,the undersigned,assume responsibility for installation of the PO�VTS shown on the attached platter. <br /> Plum s Name(Print) t/ Plumber's MPiMPRS Number BusincssPlattcNutnbcr <br /> og� o ¢ dew' � l�5 7✓ -5Gr-oZo Z <br /> Plumber's Address(Street,laity,State,Zip Code) <br /> 2 7Z2v _am,rx=n/> Welos 19^ L J r' S &Y <br /> VUI,County/Department Use Only <br /> Approved ❑Disapproved Petmh Fee P Date Issued �7 Issuing Agent Signian <br /> ❑Owner Given Reason for Denial S 37`5 , J "�7! <br /> LK.Conditions of Approval/Reasons for Disapproval <br /> nE^EaVE nn <br /> Attach to complete plans far the system and subadt to the County oniy on paper not less A 8 12 tt 2 <br /> 017 <br /> UU <br /> BURNETT COUNTY <br /> SBD-6398(R.I Ill1) ZONING <br />