Laserfiche WebLink
% '-. Industry Services Division Canty 13s-(f��ttt 77 <br /> . s 1400 E WasizOn Ave <br /> La _�_:• r' P.O.Box 7162 Sanitary Permit Number(to be fitted m by Ca) <br /> i • Madison,�4'I 53707-7162 Q 2 <br /> Sanitary Permit Applicati©n StateT`a Number 'j(� <br /> In accordance with SPS 38321(2),Wis.Adm.Cade,submission of this form to the appropriate govame l unit w2 0 7 /5 <br /> is isequied ptior to obtaining a sanitaty permit Note Application farms forstate-owned PONT are submitted to - Address(if wait than mer3irg ate) <br /> the Department of Safety and Professional Savirss Personal information you provide may be used for secondary <br /> propanes in accordance with the Privacy Law,s.15.04(lXm),Stas <br /> L Appfication Information-Please Print All Information 8t15#4All) I,Z,411- <br /> Property Owner's Name , Parcels tr 3300 <br /> agger� )- M-IARC-a J<t.t- • f{fl,A; n a7 005-.7-,-A-M1-6-5- a <br /> Property 's Mailing Address Property Location OM 66 <br /> (/'S 170 x` St-.&£7 cow!at la <br /> City,State Zip Code Phone Number y., v., Season <br /> � i$ <br /> 05e&OLA, c 51/0zo lIz-295- S'3Ly T 3� N; f a( <br /> IL Type of Banding(check all that apply) Lot 8 <br /> XI ort F:ody Dwelling- <br /> Maher of Bedrooms 3 Z Subdivision Name <br /> Block 8 NA- <br /> 0 PubtidCCommacia!-Describe Use __ 0 City of <br /> ❑state Owned-Describe Use CSM Number ❑V mgt of <br /> 4- 31 %Town of DELA t/ <br /> ( ZPie8 <br /> M.Type of Permit (Check only one box on line A. Complete Tome B if applir bre) . <br /> A- `( t <br /> New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 OtherModification to Existing System(explain) <br /> B. 0 Pewit Renewal 0 Permit Revision QList Previous Permit Number avid Date Issued <br /> t71an®e of Plumber 0 Ptrme Transler to New <br /> Before Expiration Owner <br /> IV.Type of POWYS SystendC • (Check all that apply) <br /> XNon-Presrsiaed In-Gated 0 Resstsized la-Ground 0 At-Gra to 0 Mound>24 in.ofsuitable and 0 Mound<24 in.of suitable sorb <br /> 0 Holding Tank 0 Other Dispersal Component(explain) ❑Prdrea<mest Device(ordain) <br /> V.DispersalfTnratment Area Informstbva <br /> Design Flow(gpd) Design Sod Application Rate(ppdst) Dispersal Area Regaliad(sf) Dispersal Area Proposed(sf) System Elevation <br /> 1/50 6.7 leq z.si0 psi? q 3. CO f <br /> VI.Tank Info Capacity it Total a of Manufacturer <br /> Gelkait Gallons Units 11 u o y _ <br /> New Tats Eastag Tasks w� g o ` i a Q <br /> 0 <br /> a u vs ii rat. cT.0 F. <br /> Septic°`'+•` /r 000 <br /> j(} !.CCD I Lit!E 5E JC . <br /> DesimpCbember <br /> VII.Respons�ity Se tensOt 1,the madersgaed, . ..,, responsibility for besttilatioa oldie PORTS shore se the attached plass. <br /> Plumber's Name(Print) ., .-`s S.:-. ;• MPIMPRS Number Business Phone Number <br /> 13 z u Address Kb /h aa 035'1 ,-6=:7;c5.-0yV4! <br /> Pfaaber's (Strad,City,State,Zip Code) <br /> / <br /> 7)6), )3o,'-- 9/ . A A E 'y tor - 00 i <br /> VIII.C t only <br /> ❑Owner Given Reason for Denial I 3/5 0 N 2o-xD <br /> IX.Conditions of ApprovabReasoos for Disapproval <br /> V 1)ra11.4.4C tot &WAS 4' (fie 03.1-t. ev14 LU l4 <br /> j 1?r,eu4161& t4A b(, lt ver t, '� <br /> A�/brBMeosepleeptmoa'tiespeatier,da tmibeC.anaryaskaapaperanti�thanaMn.7xIf © [E l L' E IA <br /> SBD-6398(R.08/14) <br /> APR 1 4 2020 <br /> Burnett County <br /> Land Services Department <br /> — <br />