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fI ` county <br /> r.�'�• ;rrc+ Industry Services Division Gcrn-lTttt` <br /> �$ 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ti pi <br /> P.O. Box 7162 , ) s-7S <br /> Madison, WI 53707-7162 `7- <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 Project Address(if different than mailing 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. 7.S-r/✓)t I le✓'I/Il Z4. p/s.1 f/�Iw <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel#I 1(o —3.5—.$" O.��d J /fl,r Js�i n si h 0 7-47a'.Z 4 0 <br /> peG- 617000 <br /> Property Owner's Mailing Address Property Location <br /> ?d Govt.Lot <br /> City,State Zip Code Phone Number y 1/ Section 3-� <br /> �j(JtbS{t'✓ I/Y� ylf�� e' -le one) <br /> II.Type of Building(check all that apply) Lot# <br /> T 4/ N; R /Lt Eora) <br /> i or 2 Family Dwelling—Number of Bedrooms CA t..p{✓ Subdivision Name <br /> Block# <br /> ❑Public/Cotmnercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number( n I ❑ Village of <br /> Lc UI j/ l J ,Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) 1 f <br /> A, (�New System <br /> y ❑ Replacement System ❑TreaunendHolding Tank Replacement Only El 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 <br /> IV.Type of POWTS System/Component/Device: (Check all that a pl ) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> WHolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design ]ow(gpd) Design Soil Application R=te(gpdst) Dispersal Area Required(at) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info - Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks A v u �, `v h v+ <br /> o m cd <br /> tBwpiirr Holding Tank o o bed f S/G,g�✓ X' <br /> Dosing Chamber <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 ,/ MP/MPRS Number Business Phone Number <br /> /fie /e— /5�4 /t/„,f /� l ah �s`i 7�.� G—�f�Cs'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d 77 0 3.s` 1tiLbs .• 5� 3 <br /> r <br /> un /De artment Use Onled ❑ Disapproved Permit Fee /d Date Issued Issuing Agent SignaVre <br /> ❑ Owner Given Reason for Denial <br /> $ 37�` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �Tuve /,r/eGL `nca�iaiv 1 �� ast 0r rXff fro.►t y6ZI,:w <br /> p ECOVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than g 1/2 x 11 inches i tz JUL ZIJ It <br /> SBD-6398(R0313) BURNETT COUNTY <br /> ZONING <br />