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County <br /> / ! V, Safety and Buildings Division / <br /> !fir) U &ti 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> $p � Madison,WI 53707-7162 gtoRn <br /> s x. �7 a `.'1 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Pro_ject Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary cZJLNt`_/Y,IT% <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. pp 1 t <br /> I. Application Information- lease Print All Information J (/► �- D^i ' <br /> Property Otrygr's Names Parcel# <br /> C' J 2 Zell 6!! b� z <br /> Property Own 's Mailing <br /> AddJr)e7� .v/ �/ Property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number ..14, y4, Section dkyl <br /> 5-11$s3 /y 5z G e176(oacle on5ll <br /> II.Type of Building(check all that apply) Lot# TN; R E a <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms Z 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use � <br /> El city of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> ✓: p B-Town of A-j SC <br /> III.Type of P mit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ys p y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal El Permit Revision ❑Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stenl/Com onent/Device: Check all that apply) <br /> 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.Dis ersaVrreatment Area Information: <br /> Design F—low(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elev�fiop <br /> VI.Tank Info Capacity in Total -�J#1 of Manufacturer <br /> Gallons <br /> /C(/� <br /> Gallons Gallons Units a U d <br /> New Tanks Existing Tanks d c :'• " a <br /> cC U Wti <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-f,the undersigned,as a respX,,dility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum r' igna MP/MPRS Number Business Phone Number <br /> Jac FIN 330I 115-511 --2'18 <br /> Plumber's Wdress(Street,City,State,Zip Code) <br /> A50 k lAttiX RVA k Wtbf be *400015 "IN A <br /> VIII.County/Department Use Onl <br /> Approved ❑Disapproved Permit Fee O Date Issued /^ Issuing Agent igna <br /> ❑Owner Given Reason for Denial $ 757 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RtsAttach to complete plans for the system and submit to the County only on paper not less than s 1/2 in SPR 0 5 2016 <br /> BURNETT COUNTY <br /> SBD-6398(R. 11/I I) ZONING <br />