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vEr"aretvr CountyQ <br /> Safety and Buildings Division U'w"o e:� <br /> 1400 E Washington Ave Sanitary Permit Number(to filed in by Co.) <br /> !al �So P.O. Box7162 <br /> QS Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 ) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br /> vurposes in accordance with the Privacy Law,s 15. lxm,Stars. 3� 79 eye is el <br /> L Application Information-Please Print All Information <br /> P Owner's Name eParcel# p p/ �? O/S"O ✓� <br /> ueL57 �/7 o_s"OOS v!/ae,0 <br /> Property Owner's Mailing Address Properly Location C <br /> C 5 p ItVe. Govt Lot <br /> City,State r Zip Code Phone Number y� y, Section <br /> eat)a,n©N/e W `J �J�/ circle one <br /> T �� N; R�13o� <br /> 111..Type of Building(check all that apply) Lot# <br /> ll or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑ <br /> ❑State Owned-Describe Use CSMNumber Village of <br /> —� -Town of <br /> ID.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System ❑ Treatment/Holdmg;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 6 ys3 S a 7- 78 <br /> IV.Type of POWTS System om onent/Device:TCheck an that apply) <br /> A'Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>74 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)- <br /> V.Dis ersaVTreatment Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) 7Vz <br /> roposed(sF) S � /n <br /> moo , -7 9 <br /> VL Tank Info Capacity in Total #of Manubxtraer c <br /> Gallons Gallons Units g v $ N <br /> New Tacks Fxisting Tanks <br /> °� o y' 2 u <br /> N' cw U rn U fin iw C7 R <br /> Septic or l:121ilm& aelr-- /vCr &J esC <br /> Dosing Chamber <br /> VIL 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 MPMtPR c Number Business Phone Number <br /> Plum�bber's Address(Street,City,State,Zip Code) <br /> vuL Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee 0 Date Issued <br /> ued Issuing Agent Si <br /> ❑Owner Given Rm—for Denial $ 3 7s A $'a �7 <br /> IX.Conditions of Approval/Reasons For Disapproval <br /> LECERSE <br /> Attach to complete plans for the system and sabotit to the County only oa paper not tens than 81¢x 11mi <br /> BURNETT COUNTY <br /> ZONING <br />