Laserfiche WebLink
�✓ �;�� County <br /> Industry Services Division / 4 y 14 t? <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> p '1 P.O. Box 7162 <br /> f Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (.4%P <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary G b k g <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Gt,e �i��S n l o7-odo d-ya-��-:36 ©s=a6,(- <br /> o3"f8 <br /> Property Owner's faillinng Address Property Location <br /> 1 '7765- /1141, n' e N Govt.Lot 14 <br /> City,State Zip Code Phone Number , , <br /> /, /., Section 36 <br /> s- jcircle oneL„ <br /> InG� t° C✓6 U e jY1 N T y o N; R /(p E o��%/ <br /> I1.Type of Building(check all that apply) Lot# <br /> t or 2 Family Dwelling-Number of Bedrooms 3 2 Subdivision Name <br /> m <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSNI Number p Village of <br /> Town of OAIG�G ti <br /> I11.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System VRepiacement System ❑Treatment/HoldingEl Tank Replacement Only Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Pennit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> D�N,6n Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ (folding--;Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> s— (70 O 9019 gti. <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o <br /> nU cn � 60 wV n <br /> Septic or Holding Tank MOO <br /> Dosing Chamber.. r <br /> VI1.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature // MP/MPRS Number Business Phone Number <br /> 17/c,/C !�G /c�c, S J C�j�G�cY T�' ,585`l ?iS= L " <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VHI.Court /De artment Use Only <br /> (Approved [101 Disapproved Permit Fee DDat Issue qIs mg gent Si ture <br /> 00 <br /> Owner Given Reason for Denial $ 1/ ! �� �I 1 G a <br /> IX.Conditions of Approval/Reasons for Disapproval rG III: <br /> IE <br /> D ---- <br /> APPROVED <br /> JUL 2 9 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 113 x 11 es size <br /> �� <br /> Burnett County <br /> SBD-6393(R0313) Land Services Department <br />