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%�pARTx%r� f <br />Industry Services Division <br />tngton Ave <br />County <br />�jUl(CAl�T <br />Q� �d <br />x r <br />���iSCiti <br />7162 <br />Number be filled in by Co.) <br />x <br />Sanitary Permit (to <br />Madison, WI 53707-7162 <br />6 o a7 o S <br />�.. <br />Sanitary Permit Application <br />State Transaction 94mber <br />A) <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Deparent of Safety and Professional ServicPersonal information you provide may be used for secondary <br />tmServices. Personal <br />2 7&L �� J, f(AN 4 I/ &J1� � , <br />purposesiaccordance with the PrivacyLaw, s. 15.04(1 m Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />5rfAAZG IT <br />07-036-2-11e-17-25-5 l5 - <br />Property Owner's Mailing Address <br />Property Location <br />2 (o Iv Z (� LI t_y l— 4KC—N� r !� <br />Govt. Lot — <br />— /., - y., Section 25 <br />City, state <br />Zip Code Phone <br />Number <br />(circle one <br />T ) N; R 17 E -q <br />II. Type of Building (cheek all that apply) _ / Lot <br />3 <br /># <br />% <br />Subdivision Name <br />I o 2 Family Dwelling -Number of Bedrooms— L <br />r <br />Block <br />PLkT CF _-5(ifln <br /># <br />❑ Public/Commercial - Describe Use <br />— <br />❑ City of <br />❑State Owned -Describe Use CSM <br />❑ Village of <br />Number <br />X Town of (.4A loll( <br />III. Type <br />of Permit: (Check only one boa on line A. Complete line B if applicable) <br />A. <br />❑ Nein System <br />Replacement System <br />TreatrrrenUHolding 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 />/3�3� �p s - 87 <br />IV. Type <br />of POWTS S stem/Com nent/Device: Check all that a <br />Non -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 />Design Flow (eod) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (st) <br />System Elevation <br />�sn 1 <br />0,-7 <br />1 �9J 9, <br />&sD <br />qy. <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />B <br />Gallons <br />Gallons <br />Units <br />P U d <br />New Tanks <br />Existing Tanks <br />a <br />�n <br />�' c�3 m <br />J, W C7 1~ <br />Septic o ud.-g-T �k <br />Dosing Chamber s-0 <br />VII. Responsibility Statement- 1, the undersigned, asstmite respuij4l4ty for installation of the POWTS howa on the attached plans. <br />Plumber's Name (Print) <br />Plum ;s Si r <br />MP PRS Number <br />Business Phone Number <br />-7!s= --5&6, <br />Plumber's Address (Street, City, State, Zip Code) <br />Jr <br />III. County/Department Use Only <br />Approvedwe <br />?it Feed <br />Perm <br />S, <br />Date Isssu/ed o <br />Issuing Agent Si e <br />for Denial <br />IX.asons for Disapproval <br />EV <br />Attach to complete plass for the system wW submit to the County only on paper not less than q 1 R" 11®ches in sine <br />} MAR 2 3 2018 <br />t� <br />SBD -6398 (K 08/14) BURNETT COUNTY UU <br />ZONING <br />�0 <br />