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County <br /> Industry Services Division 8"0,4-c+ <br /> 1400 E Washington Ave Sanitary Permit Nmnbcr(to be tilled in by Co.) <br /> 3 SP 1 t P.O. Box 716205� <br /> 3 S ``' Madison,WI 53707-7162 O _ <br /> X ' <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 infonuation 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 Panel# <br /> — l� �� a7-' 0l�t-a HD- IS- /3 - S /-r- <br /> I0 'v t f 0yS- 070000 <br /> Property Owner's Mailing Address Property Location <br /> 3.570 1—,et'e (iV ` Govt.Lot <br /> City,State Zip Code Phone Number y,, V, Section /:7 <br /> P �,vr" ,j-t/S 30 (circle one) <br /> GN,/1 tc r � o&IL Type of Building(check all that apply) Lot# <br /> d 1 or 2 Family Dwelling-Number of Bedrooms -� 41 3 Subdivision Name <br /> Block# .B�n -1-r-e 1 IW o y/V <br /> 11Public.�Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of TT <br /> ® Townof V-4 r-ICArH <br /> Ilf.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System Re lac tent S stem <br /> ❑TreaunenVHokling Tank Replacement Only Ell Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Pern it Revision ❑ Change of Pluutbei ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner lt7t 5�1.! _J a"U <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> VNon-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 Flaw(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 11Sd -5 `jo e Cj/' c7.1 O <br /> Vf.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> c U <br /> New TanksExisting Tanks '` u <br /> a U rn 4 r 'LZ t7 a- <br /> septic or Holding Tank �S-d / Z {ra <br /> /DSO h�.'� {r✓ <br /> Dwine Chamber <br /> V Q.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MFRS Number Business Phone Number <br /> R/Lll 770 4 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a //w v <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee O Date Issued Issuing Agent Signsmr <br /> I I <br /> ❑ Owner GivenReasnnfnrDanial S 37S ��r�` '"�S <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> EH,b EP V E <br /> Attach to complete plans for the system and subrnit to the County only on paper not less than 8 1/2 x 1 tsize <br /> fl <br /> NOV 17 2015 <br /> SBD-6398(R0313) BURNETT COUNTY <br /> ZONING <br />