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�,,i;Tg itii4,, County RR <br /> /' NP, Industry Services Division Ut.rov — <br /> ,. .t're'" 1400 E Washington Ave <br /> ,fid; �, 9 Sanitary Permit Number(to be tilled in by Co.) <br /> �,, P 1 P.O. Box 7162 j+1i3' IS <br /> ' i S , ' Madison,WI 53707-7162 <br /> Sanitary Permit Application State/TransactionNuinber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit /V e <br /> ----- <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 / <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. f 4(0 H' i? ' <br /> L Application Information—Please Print All Information <br /> Property Owner's Name Parcel# 1 73..;S 07—S—oS—00 D <br /> 4_, <br /> is dr6 h i tri t,,,n01—$l hyo e 011360— oil el e o <br /> Property Owner's Mailing Address Property Location <br /> ?S /38 f61 S7— Govt.Lot 3 <br /> City,State Zip Code Phone Number y, H, Section <br /> Sit....---- I circle one <br /> A Ave by� T 38 N; R � E o <br /> II.Type of Building(check all that apply) ) Lot# 1` _ <br /> I or 2 Family Dwelling—Number of Bedrooms Oc Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> V <br /> ^ , . 152 Town of La-ro/fere c- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) I V <br /> A. <br /> New System ❑ 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 apply) <br /> A' Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ FloldingTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> �G 0 , S' &,nb 600 93, -5— <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units _in o 0 o <br /> V N <br /> New Tanks Existing Tanks go ?? 4 y r",_a zi <br /> ❑,V c7 N ii co a. <br /> Septic or Holding Tank /0S-0 /&70 / �y/-7/11`...4,14-•✓ x <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 /> i?; , 714 /c i n S /2� 0 f-7,1%- d el.S"8�f 743—06— /S'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> d 777o M- ' 3,1' 1f/-c657`e. LvZ" Ste 813 <br /> VIII.County DepartmenE Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> —Ai Approved ❑ Disapproved `� as Q' f <br /> ❑ Owner Given Reason for Denial $37s s 7-010 -18'7 <br /> 010 -1 v tb /_/4.0 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APPROVED <br /> qui 2 a 2018 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t!?s 1 t in hes in ze <br /> BURNETT COUNTY <br /> ZONING <br /> SBD-6398(80313) <br />