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County <br /> Industry Services Division r, e-ti <br /> 1400 E Washington Ave SanitaryPermit Number(to befilled in by Co.) <br /> R PS`' r! P.O.Box 7162 CQ�OO <br /> Madison,WI 53707-7162 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 govenlmental unit G ve",L,7 Jeve,'w <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 —7 4-S A <br /> purposes m accordance with the Privacy Law,s.15.04(I)(m),Slats. <br /> I. Application Information—Please Print All Information Rd- <br /> Property Owner's <br /> NameParcel# ,yo o-.f/S—, p/ <br /> 6-erald ZrN Z o7-0*10-A <br /> o3d 000 <br /> Property Owner's Mailing Address Property Location <br /> 1968 G r%t n +-I C Govt.Lot <br /> City,State / Zip Code Phone Number y, y,, Section oZ O <br /> cz.(6 w t�e f4'1 Al �S 1.4 61 (circle one) <br /> II.Type of Building(check all that apply) Lot# T �/O N; R E o� <br /> 1 or 2 Family Dwelling-Number of Bedrooms 'd U Subdivision Name <br /> - <br /> ad LRb <br /> ❑Public/Commercial-Describe Use Block# Ji I <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> IOI Town of__0= <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System y (a,Replacement System Treatment/Holding 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 <br /> IV.Type of POWTS System/Component/Device: Check all that a 1 <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(st) Dispersal Area Proposed(st) System Elevation <br /> -- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o o <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank .S`D d•s wl <br /> rSV y( <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 /> /4 116 o/e, , if yl-s-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> '7b O A4w Ys— &.p-e 6 s IF <br /> [II.County/DepartmentrUse Only4 4Z <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent tz_ <br /> ❑Owner Given Reason for Denial % /`5' S�Z�—�� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RAF v.v YrCLou. LK = 933. 00, 119AI ' ,'ser .� Veal D E C M V <br /> T Qe /4f d art A6ovt �`ev 933,ot� <br /> Attach to complete plans for the system and submit to the County only on paper not less than a 1/2 x I1 I the sizeLUIU Ly <br /> BURNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />