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County <br /> Safety and Buildings Division ulNG�� <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit N/umber to be filled in by Co.) <br /> Madison,W153707--7162 Cjoa �t <br /> Sanitary Permit Application Statc 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 POW S are submitted to Project Address(if different thad 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).Stats. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address f//`J/ Property Locauon <br /> Y /-77 ( N1 14 Govt Lot <br /> City,Smiee� ,J�ll Zip Code/l Phone Number �y,, NW '%, Section�3 <br /> 19tron17IvV (N�^ 5'Yp'fv �{etrelamo" <br /> T�N; R I g E ot,� <br /> It.Type of Building(check all that apply) Lot;* <br /> ❑ I or 2 Family Dwelling-Number of Bedromrts Subdivision Name <br /> Block <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> III.Typ,#of Permit: (C clyonly one box on line A. Complete line B if applicable) <br /> A. New stem Replacement System Re S y p y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber=Owne7r <br /> New List Previous Pemtit Number and Date Issued <br /> Before Expiration 6 93lo(o &- 75- <br /> IV.Type of P0WTS S tem/Com nent/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 Rate(gpdsf) Dispersal Area Required(sl) Dispersal Area Proposed 1st) System Etervauon <br /> you / U t 30o 1icY,Zvi' <br /> VI.Tank Info Capacity in Total ik of Mtlnufacnvcr <br /> Gallons Gallons Units 2U u <br /> New Taniks Existing Tanks c ,y $ a a c <br /> aU rn m w r_O C <br /> Septic or Holding Tank O <br /> Dosing Chamber <br /> VII.Res risibility Statement-L the undersigned,assume responsibiBly for installation of the POWTS shown on the attached plans. <br /> Plum 's Namc(Print) Plumbers cure MPiMPRS Number Business Phone Number <br /> 651?2 11"k-SM-o2oZ <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> Z 7zoo ,Tzi Ir'�n!AGf <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing AgentSignatureApproved ❑Disapproved <br /> ❑ 00 <br /> Owner Given Reason for Denial S 3 7S'' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the s3stem and submit to the County only on paper nun less than 8112 s 11 inches V 49 UP L <br /> BURNETT COUNTY <br /> SBD-6398(R.11/11) ZONtNQ <br />