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441.92' 'e%`,,,` County <br /> �4fi ; I d� industry Services Division /3u v 0 .`/f' <br /> ifi -116''',,..1.,, -,;. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ,f"ti p til P.O.Box 7162 5-ggri(e <br /> N!,%- t. ;; ,rx Madison,WI 53707-7162 0q,v <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 requited prior to obtaining a sanitary permit, Note:Application loons 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 913.) <br /> purposes in accordance with the Privacy Law,s.15.04(1)(tn),Stats. Pete k ft <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> /NI'vt. 1< qt, 1..,..), oy- o ��a-Mrd-1G-l�-S is <br /> 39c� oy 6-laasy <br /> Property Owner's Mailing Address Property Location <br /> rt <br /> Q o& Nes(/) Ave_ Govt Lot <br /> City,State Zip Code Phone Number '4, Section <br /> Lep <br /> .Sr Pet t,.1 m/V 5-5-709 63-t- 7..s-s-- d 6 0 (circle T 4/0 N; R / oe) <br /> IL Type of Building(check all that apply) t Lot# <br /> �! <br /> I or 2 Family Dwelling-Number of Bedrooms 3 It Subdivision Name` Qfs <br /> L <br /> Block# ��1 V.0-/�I elle((.) -� <br /> ❑PubIic/Cormnercial-Describe Use J <br /> /0 ❑ City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> ®Town of OA le/idN ei <br /> III.Type of Permit: (Check only one box on line A. Complete Hoe B if applicable) <br /> A' M.New System 0 Replacement System <br /> Yp 0 Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 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 apply) , <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ‘ ❑At-Oracle 0 Mound>24 in:of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ IIolding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) • <br /> V.-Dlspersalareatment Area Information: - <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 6.eV • , Y /are' /d.to p 953/95 '/9s 8 <br /> VI.Tank Info Capacity in Total II of Manufacturer <br /> Gallons Gallons Units °' <br /> New Tanks Existing Tanks uy <br /> A-...U yr: el is .77 c. <br /> Septic or Holding Tank id ea l,Aee <br /> Dosing Chamber 7��3 e 7s-0 <br /> / S//e/ 1y/ X <br /> VII.Responsibility Statement- [,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. • <br /> Plumber's Name(Print) Plumber's Signature M4P/MPRS Number Business Phone Number <br /> ) GIG gook l Hi /Z.�h—•J a�t57, / '71.S^r�ri�a^41/5- 7 <br /> Plumber's Address(Street,City,State,Zip Code) P <br /> 2 7/n l /44r,/r 3.S kti•e dos 1-r-- �� 98,3 <br /> kApproved <br /> VVIII.County/Departmeht Use Only <br /> 0 Disapproved Pam-mit Fee O Date Issued Issuing Agent Signature / / <br /> 0 Owner Given Reason for Denial . $J 73 , g--16:1/ ' <br /> , ;,---- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEIVEI <br /> Attach to complete pians for the system and submit to the County only on paper not less than 8 in x 11 Inch:. <br /> JUL082016 Jl <br /> SBD-6398(R0313) <br /> BURNE-IT COUNTY <br /> ZONING <br />