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County <br /> z'a?r `#;• Industry Services Division 4t•xrn ew- <br /> .�7 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> PI 5 P.O. Box 7162 <br /> ri Madison, WI 53707-7162 I <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this t d'o=to the appropriate govettunental unit —!6 6 sC.1 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS 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),Stats. <br /> L Application Information—Please Print All Information <br /> Property Owner's Nat Parrel tiQ Q LAO <br /> 11 <br /> (,tJesF o/nf Cam rotcntQ z,_5 - 05, t�°1-013 <br /> Property Owner's Mailing Address Property Location <br /> //,�-O v ,rV'Cf-f Gout.Lot 1 <br /> City,State Zip Code Phone Number <br /> '/., Section AS_ <br /> S oone✓ W.:r ^5 y8� 7/r-63S= 76.Ad un (circle one <br /> Q. ype of Building(check all that apply) Lot 4 T�N; R �y E or <br /> ❑ I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> I <br /> Block# 13eo /9er'es <br /> Public/Commercial—Describe Use ���/�S''�"a <br /> ❑ City of <br /> ElCSMNumher El Village of <br /> State Owned—Describe Use <br /> nt Town of <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System ❑ Treatment/I Iolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑ PennitRevision El Change of Plumber ❑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 /> IQ NOR-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(gpdso Dispersal Area Required(so Dispersal Area Proposed(so System Elevation <br /> 660 1 .5- /ion /$ oo CIS. s' q- 9�.? <br /> VI.Tank Info Capacity in Total tE of Manufacturer y <br /> Gallons Gallons Units D v o v o <br /> New Tanks Existing Tanks •� ` v <br /> Septic or Holding Tank �islrp 15-70 d L4,/e, Y4, �p <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 NIP/MPRS Number Business Phone Number <br /> Plumber's Address(Sliect,City,State,Zip Code) <br /> III.Count /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> 8 p0 Q <br /> ❑ Owner Given Reason for Denial <br /> fX.Conditions of Approval/Reasons for Disapproval <br /> ECEIVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than R 1P-x 1 inch . in si e <br /> BURNETT COUNTY <br /> SBD-6398 (R0313) ZONING <br />