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County <br /> Industry Services Division 13"W-m-e', <br /> 1400 E Washington Ave <br /> ,¢ S 9 Sanitary Pcmtit Number(to be tilled in by Co.)P$ �, P.O. Box 7162 ���33 <br /> "i Madison, WI 53707-7162 <br /> Sanitary Permit Application State Transaction Nu Natnb <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit GodtiPy lwetj;ew <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than trailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 4 �6• 1 f✓ 4ISGA a7-od8-d-4o-lY-ld�d tyd_ <br /> 000 013 oop <br /> Property Owner's Mailing Address Property Location <br /> A9110 Me-1crorl-c- <br /> Govt. <br /> City,State Zip Code Phone Number `pot <br /> (o /a, LL /., Section <br /> 5P O 4 i1 e d •J-Y�� "7/.f Ol�r/•' ��ss(7 T '7'O N; R (circle one <br /> Q.Type of Building(check all that apply) Lot# <br /> /�/ E o& <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Cormnercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of / <br /> "town of ,.7 Ge <br /> III."[ype of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System r�yyyT <br /> reatmenUHohting Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision (❑` Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 1 ✓1�l <br /> IV.Type of POWTS System/Component/Device: Check all that apply) 1 / <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.Dispersal/Treatment Area Information: <br /> Desi ow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sO Dispersal Area Proposed(st) System Elevation <br /> ff r <br /> VI.Tank Info Capacity in Total #of Nlanutacturer <br /> Gallons Gallons Units o v <br /> New Tanks Existing Tanks m v y <br /> 2 <br /> Septic or Holding Tank f'O ��S� 2�-1 4,/ �� o✓ <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POW 1'S shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature Mt P/MPRS Number Business Phone Number <br /> Ic/GlG /7r k�„ / /Y o�dS�J` 7/S Brae—�//S�7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> -77(oev 7S We5slrr WN <br /> - <br /> VIII.Cour /De artment Use Only <br /> Approved El Disapproved Permit Fee O Date:Issued / Issuing Agent Signature <br /> El Owner Given Reason for Denial -/Zo <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEIVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Ines In size <br /> SBD-6398(R0313) APR 15 2016 <br /> BURNETT COUNTY <br /> 7r)NINr, <br />