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County IndustryServices Division�5.. 1400 E Washington Ave Sanitary Permit Number 4 be tilled in by Co.) <br /> _A. PS G P.O. Box 7162 �/; 1 <br /> . _W1 Madison, WI 53707-7162 /`-r <br /> i �P <br /> Sanitary Permit Application State Tmnsae °""number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fonn to the appropriate goveminental 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(1)(m),Slats. a 8aS 7 Fe')l /7d <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> /S,- <br /> 19-Jr O.S" <br /> Ltlil�tEw. /�pFl, p�Gl�`o�-5r0- <br /> Property Owner's Mailing Address Property Location <br /> /IOU(, llff4ptleW i>]rir+t Govt.Lot 3 <br /> City,State IZip Code Phone Number , p <br /> /., Section / <br /> 1 A r HS i t le /►'1Al 5X337 (circle one <br /> �/O <br /> IL Type of Building(check all that apply) � Lot# T N; R /.Sr E o6v <br /> 1 or 2 Family Dwelling—Nmnber of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Coimnercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Q Town of _JA-&KJA h <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System <br /> y ❑ Replacement System ❑ Treatinent/Hn)ding'I'ank Replacement Only El Other Modification to Existing System(explain) <br /> B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Pennit Transfer to New List Previous Pen-nit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Con onent/Device: (Check all that a 1 ) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.ofsuitable soil <br /> ❑ 1-lolding Tank ❑Other Dispersal Component(explain) ❑Pretreat3nent Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(s0 System Elevation <br /> 36 0 1 . SS aoe I 6eD 93 93.,E <br /> VI.Tank Info Capacity ul Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks v <br /> c. c=.U a <br /> Sepdc or Holding Tank <br /> Dosing Chamber <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 /> Rlc,IG /�,.,j f -�...� �dwS"8S J Its= 733- o 1,1 ? <br /> Plumber's Address(Street,City,State,Zip Code) <br /> )776 0 //�- a5- Lv�6s�Y, .s 3 <br /> VIII.Co7edCcOwner <br /> rtment Use Only <br /> Approvisapproved cnneeDate Isssued —tIssuing Agent Signa Given Reason for Denial $v OO 7'Oro — l ! <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> P ECEovE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1! 11 thes i i 2017 <br /> BURNETT COUNTY <br /> SBD-6393(R0313) ZONING <br />