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County <br /> rf,f. Industry Services Division <br /> •fit d 1400 E Washington Ave <br /> 9ton Saint Permit Number(to be tilled in by Co.) <br /> ps P.O. Box 7162 — <br /> so <br /> Madin,WI 53707-7162 i <br /> 59 y sss <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 mauling address) <br /> the Department of Safety and Professional Servies. Personal infonnation you provide may be used for secondary d 7�/ O �?eitL /�P <br /> purposes in accordance with the PrivacyLaw,s.15.04(1)(m),Slats. 7 Z <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name <br /> Parcel# <br /> 1%wo ir;avebl 07- 4DAPoa - <br /> 000—oi.Tesa <br /> Property Owner's Mailing Address Property Location <br /> 7/4 aaO 1 Govt.I,at <br /> City,State Zip Code Phone Number y,AP y,, Section -73 <br /> 3oL Avir% Wj SY �oo, (circle one) <br /> II.Type of Building(check all that apply) Lot# <br /> T yd N; R_/_E ot� <br /> Pf I or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> El State Owned-Describe Use CSMNunber p❑�� Village of <br /> .y Town of 64C rZ/A'1 101 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System <br /> y IT Replacement System ❑ TreannenVi Iolding'I'ank 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 /> ❑ Holding Tank ❑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 /> vsa . ,� GTao 90o qd. a <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units A. u o <br /> New Tanks Existng Tanks J° = u <br /> e, U in t� 65 k. U a. <br /> Septic or Holding Tank �Oe /fa W <br /> Dosing Chamber <br /> VII.Responsibility Statement- f,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 /> le-le, fide Ieln's <br /> Plumber's Address(Stree,City,State,Zip Code) <br /> 7760w <br /> VIII.County/Department Use only <br /> Approved ❑ Disapproved §ennit Fee Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial 33 7 7 <br /> fX.Conditions of Approval/Reasons for Disapproval <br /> nnJUN10 <br /> Attach to complete plans for the system and suhroit to the County only on paper not less than 8 to x inc in size <br /> BURNETT COUNTY <br /> ZGi4"NG <br /> SBD-6398(R0313) <br />