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cc rnmeree.wl.gov Safety and Buildings Division Coun <br /> Y18 <br /> 201 W.Washington Ave.,P.O.Boz 7162 <br /> isconsin Madison,W153707-7162 Sanitary Permit Number(to bifilledinb CCo.) <br /> Department of Commerce '55119(a W <br /> Sanitary Permit Application State saction umber L7) <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governments] (/f ea) <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) J(� 1 <br /> c-� <br /> submitted to the Department of Commerce. Personal information you Ovide may be used or secondary 6 <br /> purposes in accordance with the Privet Law,s. 15.04 1 m Stats. p 1 <br /> I. Application Infor'ease Print All information <br /> Property Owner's Name <br /> II best d" [k- v r rH I( Parcel a <br /> /2 N CYCGK CWi E (fiord.6.atr <br /> Property Owner's Mailing Address -95/S <br /> 07-v/�-.Z-3 •/S-.ZG-/0/-�yj•DIlCYY7 <br /> Property Location <br /> City,StateGovt.Lot <br /> ZiD Code Phone Number 11)C %J,J y, Section ;2 <br /> t�SGJ e n L� �jO S�3 — circle one)— <br /> _W <br /> nne— <br /> II.Type o Building(check all that apply) Lel n T_CL N; R. E Kj <br /> Tort Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block k <br /> ❑ <br /> Public/Commercial-Describe Use <br /> ❑City of <br /> ED State Owned-Describe Use CSM Number ❑ Village of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Replacement System ❑Tmatment/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 <br /> 1V.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> on-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 Rate(gpdsi) Dispers I Area Required(st) Dispersal Area Proposed(so System Elevation <br /> 7 % °� _o 3. <br /> VI.Tank Info Capacity in Total M of Manufacturer <br /> Gallons Gallons Units e k V u <br /> New Tanks Existing Tanks ii ffi <br /> �r a V in N rn ii C7 a <br /> Septic or Hdldiog-Tmk <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(Printl.-, �� Plumber's Signature MP/MFRS Number Business Phone Number <br /> � <br /> K - 2276 9% 1 _35F-2_296_ <br /> Plumbb 's Address(Street,City,State,Zip Code) <br /> L)75 S/ ;' e,-j 4,0 <br /> V I.County/Department Use Only <br /> roved ❑ Disapproved Permit Fee Date Issued Issuing Agent Si ature <br /> ❑Owner Given Reason for Denial S ��•� V'h- <br /> IX.Conditions of Approvel/Reasons for Disapproval <br /> Ihs6�lhT�n Uses AgUylade dfu OF C$i Jy Teff. AAA(,") W-03,23, 1993 <br /> -%d Md? lrid(cefep *39 D - �rry/Celt++-y�erla)a�4 Ca �le,o <br /> Attach to complete plans for the system and submit to the County only on paper not les "tSIM IlLau <br /> s a 1 <br /> OCT 10 2011 <br /> SBD-6398(R.02/09)Valid thru 02/11 <br /> BURNETT COUNTY <br /> ZONING <br />