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>= <br />Industry Services Division <br />County <br />� ►^ ht <br />v' <br />1 °�` <br />.� <br />1400 E W <br />Washington Ave <br />9 <br />Sanitary Permit Number (to be filled in by Co.) <br />Yy l t <br />P.O. Box 7162 <br />sAYU - l9 -oa <br />Madison, WI 53707-7162 <br />1<1 8 y <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 govemmentai unit <br />s - / Q 5'03- C <br />Pw� is S a <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 />8 j-b Li <br />in accordance with the Privacy Law, s. 15.04(l)(m), Slats. <br />o� <br />131 6 Ce✓ Z <br />1. Application Information Please Print All <br />- Information <br />M. r- $4 e <br />Property Owner's Name <br />Parcel # <br />Property Owner's Mailing Address <br />Property Location <br />e 13.01 1719, <br />/rt <br />Govt. Lot <br />/, y,, Section <br />City, State <br />Zip Code <br />Phone Number <br />W <br />Sy e.3o <br />7151- W 6- .17% / 7 <br />(circle one) <br />.L <br />T _! D N; P E o&? <br />Il. Type of Building (check all that apply) <br />Lot # <br />I or 2 Family Dwelling - Number of Bedrooms <br />Subdivision Name <br />j Leff / /NP SW p of <br />'ercial <br />Block # <br />❑ Public/Comm-Describe Use <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />Town of IA"1 m h <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />XReplaceinent System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑Pennit Revision <br />❑ Change <br />�e of Plumber <br />❑ Pennit Transfer to New <br />List Previous Pen -nit Number and Date Issued <br />Before Expiration <br />Owner <br />-1P /3 s /Up <br />IV. Type of POWTS S stem/Com onent/Device: (Check all that apply) <br />❑ N:on Pressurized In -Ground ❑ Pressurized fn-Ground ❑ At -Grade IQ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ HoldingTank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treat ent Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (sfl <br />Dispersal Area Proposed (st) <br />System Elevation <br />4y o <br />/. o <br />ysa <br />Z/( a <br />9 Y. 7s- <br />V1. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />" <br />o <br />New Tanks <br />Existing Tanks <br />w <br />2 o <br />y Na <br />u U <br />n <br />Septic or Holding Tank <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 />NIP/MPRS Number <br />Business Phone Number <br />Plumber's Address (Street, City, State, Zip Code) <br />% 70 p is/w . _�S tV_.e b f r`Y._ <br />V Il. County/De artment Use Only <br />Approved <br />❑ Disapproved <br />Pennit Fee <br />$ 37s °� <br />Date Issued <br />'7-./gat <br />Issuing Agent Signature <br />[I Owner Given Reason for Denial <br />�- <br />IX. Conditions of Approval/Reasons for Disapproval <br />ECEWE Tj:�) <br />APMPROVED ID <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 s 1Itt <br />hes usizetj� <br />SBD-6398 (R0313) <br />BURNETT COUNTY <br />ZONING <br />