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>.i,N'3ar,�•�':,'.,. County <br /> Industry Services Division LJ U e in -e <br /> X! S ' 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> '5 •` PS �`'' P.O. Box 7162 <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383 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 mailing address) <br /> the Department of Safety and Professional Setvies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04([)(in),Stats. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel tt <br /> /30� f�.s kl o7.61a-a- 4o-,s-a8-s ,S,�bo <br /> adRovo <br /> Property Owner's Mailing Address C Property Location <br /> ) 73y r Char -5 lex Rl7'II' Govt.Lot <br /> City,State Zip Code Phone Numberi� 8 <br /> Section <br /> (circle one) <br /> 11.Type of Building(check all that apply) Lot tt Q T 40 N; R /S E or W <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms p Subdivision Name <br /> Block k � <br /> 11tm <br /> PubliciComercial-Describe Use <br /> ❑ city of <br /> 11State Owned-Describe Use CSN[Number ❑ Village of <br /> li Town OF C-/C.5 h <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System X Repla^ent System ❑Treannent/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> 6. ❑ Permit Renewal ❑ Permit Revision ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS Sys tem/Comonent/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-0mtle ❑ Mound L 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 Plow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sL) Dispersal Area Proposed(st) System Elevation <br /> 3400 . -2 1 `-'d 9 1 //zls- <br /> VL Tank Info Capacity in Total I of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existine Tanks u <br /> aJ v, n r rz -5 G <br /> Septic or Holding Tank 7s— <br /> Dosing <br /> -- <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 Ni PiMPRS Number Business Phone Number <br /> I -lC ��O �Gih t � f� p2� S-/ '7/S-00011 - y/.S-7 <br /> Plumber's Address(Sadlet,City,State,Zip Code) <br /> 77 3,�— ILfJ e6 s fY� I S�/$93 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit <br /> 'Fee <br /> !j 0 Dale Issued Issuing Ag t S�gnanv <br /> 6 <br /> El Owner Given Reason for Denial 5 376' <br /> " . -3-/S <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> In <br /> C Q <br /> 7 W. n <br /> Attach to complete plans for the system and submit to the County only on paper not less than B 1 x t The. th si:e <br /> BURNETT COUNTY <br /> SBD-6393(R0313) <br /> ZONING <br />