Laserfiche WebLink
/.T�. <br />-• `4:„: <br />Industry Services Division <br />County <br />i3 tot rh -e <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Sanitary Permit Number (to be tilled in by Co.) <br />Pj <br />5f1A) - ]y —// <br />(� <br />Madison, WI 53707-7162 <br />60935 <br />Sanitary Permit Application <br />State Transaction Number <br />Al ' <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate govenunental unit <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 Servies. Personal information you provide may be used for secondary <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />`-- <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel -A-3 9,. <br />TOM ar Noah 6APh 6-0 i <br />04�” d1,1 boo <br />Property Owner's Mailing Addre s <br />Property Location <br />)47.3 G l G,. e k fied <br />as rl -c <br />Govt. Lot Q <br />/,'/4, Section a <br />City, State <br />Zip Code <br />Phone Number <br />_7 (3 <br />(circle one <br />T N; R !y E o& <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />❑ 1 or 2 Family Dwelling - Number of Bedrooms <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned — Describe Use <br />❑ Village of <br />CSM Number <br />Town of <br />III. Type of Permit: (Check only one bot on line A. Complete line B if applicable) <br />A. <br />❑ New System5 <br />iReplacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Pen -nit Revision <br />❑ Change of Plumber7E]Pe--nit <br />Tasfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />IV. Type of POWTS S stem/Com onent/Device: (Check all that apply) <br />J9 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 (gpd)Design <br />Soil Application Rate(gpdst) Diso rs1aI a Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />�.s o <br />VI. Tank Info <br />Capacity in <br />Total # of <br />Manufacturer <br />Gallons <br />Gallons Units <br />D <br />o <br />u <br />Vi <br />New Tanks <br />Existing Tanks' <br />c. U0 <br />Y <br />_� <br />U <br />C.. <br />Septic or Holding Tank <br />Q S'D <br />I <br />r <br />H �' , ►� R t� O <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 Signatur <br />NIP/MFRS Number <br />Business Phone Number <br />IG&( <br />lof <br />Plumber's Address (Street, City, State, Zip Code) <br />-17 O e.✓ <br />VIII. Cour /De artment Use Only <br />rfMpproved <br />ElDisapproved <br />Permit Fee <br />Date Is/sued <br />Issuing Agent Signature <br />El Owner Given Reason for Denial <br />$ -3! <br />Q <br />b — v <br />4/��= <br />IX. Conditions of Approval/Reasons for Disapproval E S E � � E <br />nnSEP ft <br />0 5 2018 <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2.X ff- <br />inch14 in size <br />BURNETT COUNTY <br />ZONING <br />SBD -6393 (110313) <br />