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Alibis COmmerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 r/U <br /> 'Wisconsin Madison.WI 53707-7162 !�i7 <br /> it Number(to be filled in bldd,..) <br /> e sartrnern of Commerce ^ <br /> Sanitary Permit Application j.;Nmob.,In accordance with a.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governmental7 <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Prdds(if different than mailing <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,a.15.0 1)(m),Stars. <br /> I. Application Information-Please Print All Information rte, <br /> Property OwnerA,v's N e f J� Parcel N ,00 .30 ,O U 1 <br /> e N �/Girl , 1 I�s 07-006-2-317-/3- G/7srb <br /> Property Owner's Mailing Address /I / Property Location <Z- <br /> 1-17 3 to CcJ�¢ o�� f/(1 O// <br /> City,Stare Zip Code Phone Number Govt Lot <br /> 2 v., Section <br /> � � circle one�lar� <br /> 'F—9 N; R _E ti <br /> IL Type of Building(check all that apply) Lot k - - <br /> Family Dwelling-Number of Bedrooms__. _ ._ Subdivision Name <br /> Black N �� <br /> ❑Pubadm <br /> Comereial-Describe Use �- _ <br /> ❑ City of <br /> 11 State Number L1Villaeof State Owned-Describe Use B <br /> 7-Town of <br /> IIL Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. d New )e <br /> System Riplacemenl system Y y ❑ TreatmenUHolding'fank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renmal ❑Permit Revision ❑ Chan eofPlumber List Previous Permit Number and Date Issued <br /> g ❑Permil'rramfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com im t/Device: Check all that apply) <br /> �e <br /> 0 Non-Pressurized In-Ground ❑Pressurized In-Ground El Al-Grade ❑ Mound'>24 in.of suitable soil XWound<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 plication Rxle(gpdsf) Dispersal Area Required(sf) Dispersal Area Pro sed(af) System Elevation <br /> 5`so -Sir /,s3 <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallon Unita <br /> a E U <br /> New Tanks Existing Tanks u c � y y p <br /> d: U '.n S A w c7 w <br /> Septic mg Tank 60 I/00�- d <br /> Dosing Chamber O <br /> VII.Responsibility Statement- t,the undersigned,assume responsibility for installation orthe POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatum MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,Stale,Zip Code) <br /> VIII.County/Department Use Ont <br /> ff�Approved El Disapproved permit Fce� Date Issued Issuing Ag ;tare <br /> ❑Owner Given Reason for Denial '�"� .Cry I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �J <br /> Attach m complete pram for she system and submit to the County oNy on portions les therif t all inch.Insize <br /> SBD-6398(R.01/07)Valid thin 0Y09 MAY 2 5 2001 <br /> BURNETT COUNTY <br /> ZONING <br />