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C'oun� <br /> Industry Services Division (S4f K e# <br /> 0 w 1400 E Washington Ave Sanita Permit Number to be tilled in b Co.) <br /> �S PS . i P.O. Box 7162 Ccjr,� ( y <br /> �,•. `� Madison,WI 53707-7162 SOV <br /> Sanitary Permit Application State Transaction nnNuiliber <br /> In accordance with SPS 333.21(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 trailing address) <br /> the Deparent of Safety and Professional Servies. Personal information you provide may be used for secondary I <br /> purposes itm �rn accordance with the Privacy Law,s. 15.04(I)(m),Stotts. 3 o 3 to 9 j3c-,-q L lc <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> 66 u1f9-S--/S— <br /> NOr—��n nfNY �r0 KY Tie ti41-*A0000 <br /> Property Owner's Mailing Address Property Location <br /> c 'r, 3 C • - 5 Govt.Lot <br /> City,State Zip Code Phone Number t <br /> /., /., Section �g <br /> aye*P1 /74 Al SS O SG7-d o$-D63,S" 1jctrcleone) <br /> It.Type of Building(check all that apply) Lot# T 4 N; R /.S` E or W� <br /> l or 2 Family Dwelling-Number of Bedrooms_ 7 / Subdidsion Name <br /> Block# <br /> ❑Public/Couunercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `�' ❑ New System ❑ Replacement System ❑Treatmenv Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> !�n /n r d f f <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner I�0 — <br /> IV,Type of POWTS Svstem/Com onent/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sY) System Elevation <br /> le - 7 1 /7019 <br /> VI.Tank Info Capacity in Total #of Manufacturer a, <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks v v J m q <br /> e- <br /> Septic or Holding Tank 1 s �.A 5-V 1 IN t-e$-C r .� <br /> Dosing Chamber 0� <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 /> rale 2/� /Cfrs J A,(s8.s-1 7'/S=?4h- y/S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Cour /Dc artment Use Only <br /> Approved ❑ Disapproved Perrm iit7Fee D Date Issued Issuing Agc Signature <br /> ❑ Owner Given Reason for Denial �3 !�` c1:3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> q <br /> ECEovE <br /> Attach to complete plans for the system and submit to the County only on paper oat less than g IR x 11 inche a si <br /> BURNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />