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t. s�sty�, County <br /> Industry Services Division <br /> 3 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> SPVI P.O. Box 7162 Q <br /> S Madison,WI 53707-7162 'goS3aJ <br /> `,'at'rKa.;4 J7'Y L <br /> Sanitary Permit Application State Transaction Number <br /> 1n accordance with SPS 383.21(2),Wis.Adm.Code,submission of tris 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 be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. <br /> L Application information-Please Print All Information tt 1/le,.,,e Cr t <br /> Property Owner's Name Parcel# y6-1 d u�.��S='�Oo-O 7 3^• <br /> Y► t <br /> ��/�ArG !✓� /G1 1.40 pf'isQ <br /> Property Owner's Mailing Address Property Location <br /> /3 4Y ,9 s c3ra ss Pty w tr Govt.Lot <br /> ('try,State Zip Code Phone Number !, ' Section pl <br /> ltd $>eM0CA0 "O&S (circle one <br /> TN; R_LEo '.' <br /> [[.Type of Building(check all that apply) Lot �� <br /> 91 or 2 Family Dwelling-Number of Bedrooms 3 pal, Subdivision Name / <br /> Block# e, I Kax rpen AA4, k/ I <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use 7Number ❑ Village of r <br /> - -- 4' Town of .JaGI«O <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. p New System IXReplacetment System ❑ 1'reatmenhHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ' ❑Permit Transfer to New 4 List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 9 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(s I) Dispersal Area Proposed(st) System Elevation <br /> k5-0 . 5- go el 9(7a C s <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> v <br /> Gallons Gallons Units � � U <br /> New Tanks Existing Tanks L R m <br /> a U u- U a <br /> Septic or Holding Tank /401) 10oel (�J(1Lf�C✓ <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> prole- 1-16,,d le s <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 *>- 3.5' <br /> VIII.County/Department Use Only <br /> Approved El Disapproved T$P ermit Fee Date Issued Issuing A t Sign re <br /> ❑ Owner Given Reason for Denial J 5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D ECEOVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 i ize <br /> SEP 4'2015 U 0 <br /> SBD-6398(110313) BURNETT COUNTY <br /> ZONING <br />