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commercemi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 ou r n e� <br /> tisconsin Madison.Wl 53707-7162 Sanitary Permit Numb"(to be filled in by Co.) <br /> Depertmerrt of Commerce $2/ Q/& <br /> Sanitary Permit Application Sure Transaction Number ` <br /> In accordance with a.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental -� \�\J <br /> unit is required prior to obtaining a sanitary permit. Note: Application forma far stale-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary -f <br /> purposes in accordance with the Privacy Law,s.I5.04(I)(m),Stats. <br /> L Application Information-Please Print All Information - <br /> Property Owner's Name � Parcel# . <br /> 3a9 <br /> Jotin h+kn//1on Cher/ Brtwn mgp y„a 035 33 dc/ 400 <br /> Property Owner's Mailing Address Property Location <br /> 9,173 8eec It St• Govt Lot 1 <br /> City,State Zip Code Phone Number Yy Yy Section J,-' <br /> -7it4• pa W( M At SS(/ y (circle on <br /> IL Type of Building(check all chat apply) Lot# ^ —E o <br /> lXIL1 or 2 Family Dwelling-Number ofBedrooma 4- Subdivision Name <br /> Block# <br /> ❑Public/Cmanamniat-Describe Use <br /> ❑ CiTy of <br /> 11 State Owned-Describe Use CSM Number El village of <br /> B'Town of SwrJS <br /> IIL Type of Permit: (Check only one box m lite A. Complete fine B if applicable) <br /> A. ❑New System pr Replacement System ❑Treahaent/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑ Change of Plumber 1 ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expkation Owner <br /> IV.Type of POWTS System/Comp onenVDevice: Check all that apply) <br /> 0 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.Dis ersanmabment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3'oe I . -7 &/d 9 y sit <br /> VL Tank Wo Capacity in Total #of Mamufacturer <br /> Gallons <br /> Gallons Units yes $ ,p <br /> New Tanks Eximag Tanks U <br /> `ii £ U $ a <br /> do m9- w iL c7 <br /> SepiaorHoWiog Tank 7f"p >sb L(l G. <br /> Dosing chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Siignature MP/MPRS Number Business Phone Number <br /> /p/L rfL /crnJ /c -y /'r oipt.f-B.S-� lis-1sYod- 4Zs-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,A7760 />/w 3S� klebs><<i Gf>1S`4t43 <br /> VIIL Cozen /De artment Use Only <br /> ❑ Approved ❑Disapproved PermutFee Dpoh issued �{ Issuing Sigtuturo <br /> ElOwner Given Reason for Denial �✓/Ir(r) Q(J <br /> DL Conditions of Approval/Reasons for Disapproval <br /> t�illr <br /> i� �c� i <br /> � � <br /> I <br /> Annobtoeoapteh plamfurthesyrtea and subaktothe Countyadym pap.,ant Bin. <br /> SBD-6398(R.01/07)Valid thm 01/09 BURNETT COUNTY <br /> ZONING <br />