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County 7 <br /> �� r Industry Services Division 1j yt,Y„ — <br /> 41` �- "r+%� 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> s p <br /> P. P.O. Box 7162 RS� !1?� <br /> $ Madison,WI 53707-7162 1 I <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 fors 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 7 p f' Gee Fd U <br /> 1. Application Information-Please Print All Information O <br /> Property Owner's Name Parcel# <br /> �D.Q ,- Ril-e S 07-- ol.o-3-NO- <br /> Property Owner's Mailing Address Property Location <br /> 1 -76147 t ks,-t✓ /4✓e Govt.Lot <br /> City,State Zip Code -7 Phone Number %, Section .1O <br /> PA34- ;q 5 N �09i J T �/� N; R�(circ]E ore® <br /> II.Type of building(check all that apply) L # <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms 3 X-I, /0,4 of C Suh ivision Name <br /> loLaL <br /> rs-) <br /> _ qL0Public/Cormnercial-Describe Use ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> - 3 ? 1O d,t IR Town of (::Pa)G1^i,% <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System )?LJreatmenUHolding Tank Replacement Only ❑ Other Modification[o Existing System(explain) <br /> ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit N mber and Date1ucd <br /> B. 11 Permit Renewal El Permit Revision _ <br /> Before Expiration Owner - 'D� <br /> IV.Type of POWTS S stem/Com onent/Devicet (Check all that apply) <br /> 9 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable oil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) I Dispersal Area Required(st) Dispersal Area Proposed(si) System Elevation <br /> "0_0 1 630 eXlst;h <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units Z <br /> New Tanks Existing Tanks v c v u <br /> o _ <br /> c U rn mvi t.-U C <br /> Septic or Holding Tank �B JY-© 16,3'0 }h fY ti <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/ PRS Number Business Phone Nuinber <br /> 411N s / 7is=�6G �•'�-S 7 <br /> Plumber's Address(Stree,City,State,Zip Code) <br /> 7 7 e 31f- <br /> VIII.County[Departmenf Use Only <br /> ElApproved ElDisapproved Permit Fee Date Issued Issuing Agent Signature <br /> a <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval easons for Disapprov <br /> Sfee� T•¢.vK 404trexteovf W ECEIVEnn . <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112. 1 in s in sjZe•� er <br /> JU L Zp16 UU <br /> SBD-6398(R0313) BURNETTCOUNTY <br /> ZONING <br />