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►i� County 7 <br /> Industry Services Division X W#1_1!11� <br /> Us P! r1 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> Madison,WI 53707-7162 _63N/R--, <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 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 -7-7 etA <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information 4B 1-2d u <br /> Property Owner's Name Parcel# <br /> 0a.0 t R/-es <br /> Property Owner's Mailing Address <br /> / Property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number '/., Section l7 <br /> jctrcle one) <br /> 11.Typeof Building(check all that apply) Lot# T jD N; <br /> Lot R �(� E or® <br /> CjGr«.SC ui rq <br /> I or 2 Family Dwelling-Number of Bedrooms y`O i tY- Subdivision Name <br /> Block# <br /> VI I hC - <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use C1P, IDA SM Number IDA <br /> El Village of <br /> (/ �1 <br /> V .3 Town of OG/c/¢no6 <br /> Ht.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Chane of Plumber List Previous Permit Number and Date Issued <br /> Change ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POINTS Sys tem/Comonent/Device: Check all that apply) <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 Raw(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> iso 17 01 /11 .01 /6 1 47 y. d <br /> Vt.Tank Info Capacity in 'Total #of Manufacturer <br /> Gallons Gallons Units c J <br /> New Tanks Existing Tanks v o m 15 y a <br /> �V m y rn CZ c. <br /> Septic or Holding Tank O �� Q t�/�S t•r )� <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> of 7 7 6 e /S/,, 3.� LcJebsy. /�� SS`�53 <br /> VIII.CountyfDepartmeiit Use Only <br /> tApproved ❑ Disapproved Permit Fee Date Issued Issuing Ag t -gra <br /> 7 0 <br /> ❑ Owner Given Reason for Denial 5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> /tom "� Attach to complete plans for the system and submit to the County only on paper not lessAinchesR 2.0 2015 <br /> 'C01'Ej <br /> SBD-6398(R0313) BURNETT COUNTY <br /> ZONING <br />