|
-4,--7,',;s2741&4:-.., County
<br /> ' `�
<br /> `' Industry Services Division V. Weil—
<br /> ;
<br /> .iL
<br /> ,Y t 1. D1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.)
<br /> ` ts� P.O. Box 7162
<br /> '+'!.::= %IN o�-
<br /> : t
<br /> '� Madison, WI 53707-7162
<br /> State Transaction Number
<br /> Sanitary Permit Application (073 Till
<br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit
<br /> is required prior to obtaining a sanitary permit. Note:Application forms For state-owned POWTS are submitted to Project Addrgss,(if different than mailing address)
<br /> the Department of Safety and Professional Servies, Personal information you provide may be used for secondary A 9.1 ie A
<br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 1
<br /> I. Application Information-Please Print All Information �/n 2 lCN• l/ Li,v.
<br /> Property Owner's Name Parcel# yO_# ill_ AS'--.Sr /s"
<br /> ,),14 iafIiAm /fie/loc/- a�-od8 d-
<br /> s>G--ot/o®o
<br /> Property Owner's Mailing Address / Property Location i1 i f t,:1'
<br /> /7 z/.S'O ,)k N t f'j<v'v cam✓`' Govt.Lot
<br /> City,State Zip Code Phone Number y, y,, Section
<br /> 1,a It.c v;(t e MA/ .CIO yy (circle one
<br /> T VO N; P. /y E or
<br /> II.Type of Building(check all that apply) Lot#
<br /> Di I or 2 Family Dwelling-Number of Bedrooms
<br /> OI / Subdivision Name
<br /> Block# V. K P /7$
<br /> ❑Public/Commercial-Describe Use 3 ❑ City of
<br /> CSM Number ❑ Village of
<br /> ❑State Owned-Describe Use
<br /> y Town of SGO
<br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)
<br /> A' ❑ New System y 1Y Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other iv[oditication to Existing System(explain)
<br /> B ❑ Change ❑Permit Transfer to New List Previous Permit Number and Date Issued
<br /> ❑ Permit Renewal ❑ Permit Revision of Plumber
<br /> Before Expiration Owner
<br /> IV.t' se of POWTS S stem/Com.onent/Device: (Check all that a.ill )
<br /> Nor PtekiniPiied In-Ground ❑ Pressurized In-Ground ❑ At,Grade ❑ Mound 24 im of suitable soil ❑ Mound<24 in.of suitable soil
<br /> ❑-Eiolding:Tank ❑Other Dispersal Component(explain) ❑Pretreahnent Device(explain)
<br /> V,Dispersal/Treatment Area Information:
<br /> Design Flory(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation
<br /> 3 0 0 . 7 el/J-/ 'rso 9i'. O
<br /> VI.Tank Info Capacity in Total #of Manufacturer AI
<br /> Gallons Gallons Units o ,,, o
<br /> New Tanks Existing Tanks ' o v ca cs
<br /> n,U cn 11, cn iz V a.
<br /> Septic or Holding Tank 7.5 b 74 a / £VJ/e fe
<br /> Dosing Chamber.. l :}
<br /> VII.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 NIP/MPRS Number Business Phone Number
<br /> jet c-/c 5 /i Alit-- dAs'=s"/ 7/J--: . 0-.q/ ->
<br /> Plumber's Address(Street,City,State,Zip Code)
<br /> 776 o )54.....? mss` G'e6,04e.-- >1J>-.s?/S-'5'..
<br /> VIII.County/Department Use Only
<br /> C9.pproved ❑ Disapproved Permit Fee Date ssu gent Si�ortature
<br /> ❑ Owner Given Reason for Denial $ 31.O6 5 1, 22.0 /R�� /.A —
<br /> IX.Conditions of Approval/Reasons for Disapproval � NV
<br /> it VUIu,0 Luwt c ob5,00.Ftov, optspts per cttl. fenE C E I V
<br /> X 1)04,,JteL6 must 5ft .,,,,. Qeih t . sok- it Okt )Wt. D
<br /> if Ex,1+i45, Stsfew MU$ let W./4441m ( per SPS 383,
<br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/?x 1l inc I in i.•
<br /> Burnett County
<br /> SBD-6398(80313) Land Services Department
<br />
|