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.:erirtc?„y.a County <br /> Safety and Buildings Division <br /> `. DS �<# 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> `z P S _J Madison,W1 53707-7162 <br /> �l X11 <br /> C� /CJI 10 <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 govcmmental 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(I)(m),Slats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> N A -zr �,Z -y OZ—e00-0I1 0 <br /> Property Owner's Mailing Address Property Location <br /> zglzy 6W Govt.lot <br /> City,State <br /> �f L 1 r /Zip Code Phone Number,,,�-y q ILL y��v, section 2 <br /> w e�*k W a 7 T�g ��X17! U ----LLLL�--������ �c rete one <br /> I1.Type of Building(check all that apply) Lot# T #0 N; R E <br /> ( _ <br /> 1I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village ofTown of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System I*Replacement system ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal F-1 Permit Revision <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rale(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> fob . 7 1 glZ 7 1 y2 9G 9 H <br /> V I.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o u_ <br /> New Tanks Existing Tanks e e o 2 a <br /> c, U M w rA {1..V a. <br /> Septic or Holding Tank <br /> Dosing Chamber f7 r/ �•J <br /> VQ.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plaits. <br /> Plum s Name(Print) Plumber's _ turc MPIMPRS Number Business Phone Number <br /> o45� e� 8S1 gS 1i5-SM-ozo Z, <br /> Plumber's Address(Street,City,State,Zip Code) <br /> A� <br /> �VUL County/Department Use Only <br /> y�Approved ❑Disapproved Permit FeeDate Issued Issuing Agent Signature <br /> /\ ❑Owner Given Reason for Denial s 375• O 17,-71 -1(a <br /> IX.Conditions of ApprovalfReasons for Disapproval <br /> ECEIVE -n-) <br /> Attach to eompkete plans for the system and submit to the Counh•only on paper not leas than 8 in x 1 'n size <br /> JUL 21 2016 <br /> SBD-6398(R.11/11) BURNETT COUNTY <br /> ZONING <br />