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.eft <br />Industry Services Division <br />County <br />Pi <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Sanitary Permit Number (to be tilled in by Co.) <br />Madison, WI 53707-7162 <br />3a <br />Sanitary Permit Application <br />State Transaction Number <br />Sty� <br />_ <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 fonns for state-owned POWTS are submitted to <br />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 />a a '10-7 <br />purposes in accordance with the Privacy Law, s. 15.04( 1) (m), Stats. <br />I. <br />Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />o7-oy�3Y-sor ao7 <br />o m o0 <br />a�a�t <br />v� <br />Property Owner's Mailing Address <br />Property Location <br />9Cf W %.4 A 6 t. r ,% i4�,e S <br />` ` <br />Govt. Lot <br />[A y., Section <br />City, State <br />Zip Code <br />Phone Number <br />1 Al3 <br />rY< O <br />circle one) <br />8 <br />T 3 N; <br />II. Type of Building (check all that apply) <br />Lot # <br />P1 or 2 Family Dwelling — Number of Bedrooms <br />A <br />Subdivision Name <br />Block # <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />El State Owned —Describe Use <br />❑ Village of <br />CSM Number <br />Town of w of J �� v -e <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A, <br />❑ New System <br />,�Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS System/Component/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 />0 Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf)Dispersal <br />Area Required (so <br />Dispersal Area Proposed (st) System <br />Elevation <br />o O <br />�— <br />— <br />-- <br />VI. Tank Info <br />Capacity in <br />Total # of <br />Manufacturer <br />Gallons <br />Gallons Units <br />o <br />New Tanks Existing Tanks <br />��° <br />o v <br />Y <br />a <br />U Cn <br />Cn <br />Septic or Holding Tank <br />3 400 0 <br />3000 , <br />iv i r S C ✓' <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) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />7/s7 -?,G6; <br />Plumber's Address (Street, City, State, Zip Code) <br />7 760 .51u„ 3s— A/,_- <br />t/-cVIII. <br />VIII.Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee O <br />Date Issued <br />Issuing Agent Signatu -----7 <br />❑ Owner Given Reason for Denial <br />3 7S' <br />Q' <br />v Q � � �' U <br />IX. Conditions of Approval/Reasons for Disapproval <br />E C E V <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 u <br />x I I illches in size <br />AUG 21 2018U) <br />s;BU-6398 (110313) BURNETT COUNTY <br />ZONING <br />