Laserfiche WebLink
.+saa�u w --p— porus tv1 tuc systcm amu suouut to the %-ounty Only on paper not cess than !f v2 }iigC eLQU [E 0 p /J E <br />SBD -6398 (R. 08/14) JUL 19 2018 <br />BURNETT COUNTY <br />r <br />Industry Services Division <br />Coun� s <br />' <br />_ <br />1400 E Washington Ave <br />Urdj <br />Samtary Permit Num er t e illed in by Co.) <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />Ck 31 <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />/l/1* - <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />0 <br />u oses in accordance with the Privacy Law, s. 15. 1 m , Stats.q <br />ya 11 <br />l <br />I. <br />Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel #O,- 0/y' J <br />017-00/- 0111101q0 <br />Property Owner's Mailing Address <br />Property Location <br />G-A 4 <br />City, State tip Code <br />Phone Number <br />Govt. Lot <br />�� 1 1A, Section <br />/J U J <br />T - N; R 1 lE oaU�) <br />t% <br />11. Type of Building (check all that apply) <br />Lot # <br />X1 or2Family Dwelling - Number ofBedrooms <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑State Owned -Describe Use <br />❑ Village of <br />CSM Number Ga✓Lo 1 <br />V G I / -If <br />l ) <br />1,C& <br />Ix Town of C 2 �l � / f� <br />111. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />gNew System y <br />❑Replacement System <br />❑ Treatment/holding Tank Replacement Only <br />El 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 <br />of POWTS System/Component/Device: Check all that apply) <br />tNon-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 />Desi Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Arga Prosed (sf) <br />S stem Elevation <br />l/9j rv7 <br />�t Z �� <br />yso - y <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufactbrer <br />Gallons <br />Gallons <br />Units <br />o <br />New Tanks Existing Tanks <br />0 o <br />n <br />0. U <br />ti <br />is; C7 <br />0. <br />Septic or Holding Tank <br />74 <br />{ J <br />1 <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />PI u er's Name (Pr t) <br />Plumbe ' Si azure <br />MP/MMPRSS Number <br />Business Phone Number <br />CJ � <br />P umber's Address (Street, City, State, Zip Code) <br />VV CSG dna (i �/(✓ �' <br />lI. County/Department rsef6nK <br />Approved <br />El Disapproved IT, <br />mit Fee <br />D <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />7 <br />7S' B <br />IX. Conditions of Approvai/Reasons for Disapproval <br />APPROV[D <br />.+saa�u w --p— porus tv1 tuc systcm amu suouut to the %-ounty Only on paper not cess than !f v2 }iigC eLQU [E 0 p /J E <br />SBD -6398 (R. 08/14) JUL 19 2018 <br />BURNETT COUNTY <br />r <br />