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ON COMPUTERIS(3ANNED <br />SBD -6398 (R. I Illi) BURNETT COUNTY <br />7nNIN[, <br />County <br />y- Safety and Buildings Division <br />A/e <br />Sanitary ermit Number (to be filled in by Co.) <br />_ 201 W. Washington Ave., P.O. BOX 7162 <br />SP~) Madison, WI 53707-7162��O�U <br />__....,- <br />State Transaction Number <br />Sanitary Perrnit Application <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate govemmental unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned PONTS 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 />purposes in accordance with the Privacy Law, s. 15.04(t)(m). Stats. <br />'7 TTT77l���%%% <br />Z2rr 1 N <br />Parcel r <br />1. Application Information — Please Print All Information <br />Property Owner's Name <br />dj lly,- <br />02� <br />Propeny Owners MailingAddress <br />Property Location <br />1265"Z �14h1 n! <br />Govt. Lot 2 <br />y,, '14, Section <br />IE <br />City' State <br />Zip Code <br />116049 <br />PhoneNumber <br />y,� �;%%� <br />(;C 0N, K/� /1N v <br />61.7-7.7-0-00 <br />? <br />T ✓ 8 N. R �J orW <br />H. Type of Building (check all that apply) <br />Lot i <br />A <br />Subdivision Name <br />i or 2 Family Dwelling -Number of Bedrooms — <br />/ r <br />Block = <br />, <br />/! AJ-fiii <br />❑ City of <br />❑ Public/Commercial - Describe Use <br />❑ State Owned -Describe Use <br />❑ Village of <br />ATown of \% <br />CSM Number <br />Ill. 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 />P <br />❑ Other Modification to Existing System (explain) <br />B. ❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />11Permit 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 <br />❑ Mound <24 in. of suitable soil <br />Holding Tam, ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Acquired (sf) <br />Dispersal Arca Proposed (sf) <br />System Elevation <br />Vi, T ank Info <br />Capacity in <br />Total <br />r of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />U <br />New Tanks I <br />EcistingTanks <br />L <br />'rn <br />Septic or Holding Tank <br />Dosing Chamber <br />ViI. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the PONVTS shown on the attached plans. <br />Plunt s Name (Print) Plumber' aturc MPr1v1PRS Number Business Phone Number <br />—02-0 Z. <br />Plumber's Address (Street. City, State, Zip Code)) / <br />Ao <br />V111. Countyl"Depart hent Use Only <br />Approved <br />I ❑Disapproved <br />Permit Fee <br />Date Issued <br />!suing Agent Signature <br />I` <br />S37S <br />)r-3-1-) <br />❑ Owner Given Reason for Denial <br />IX. Conditions of Approval/Reasons for Disapproval_ <br />T t-��Jar �aa� r'Io�hi a <br />L/ <br />Attach to complete plans for the system and submit to the County only on paper not less than S <br />57 <br />nches in size <br />NOV 01 2017 <br />SBD -6398 (R. I Illi) BURNETT COUNTY <br />7nNIN[, <br />