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tDopartnomft <br /> of Commerce Safety_nd Buildip s Dn i ton ce �+t01 W.Washington hle r U Iso;:_/til's'cons'n Madkam Wl 53707-7(62 <br /> S.mt,ry Parma Numbs-r(fu b„Fil;o mby CoJ <br /> _ — <br /> St +J. Tt- crap Dhimbn� -- <br /> I5ailii Iry Permil AppReatioa-i / <br /> hr accordance with s Contra 83.21(2),Wis.Adm.Code submission of this form to the appropriate go�^snr.�zntal 0�''f1�J /BVI�f1� <br /> unit is required prior tq' obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project r ddress(iidifferent than mailing address)) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary -6 mur rosesinaecordance ith the Privacy •�Law,s.15.04(1)(.),Slats. �Lbdl�j (/ran h,(M (-1C Dr. <br /> I. A Bcation Infor ation-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 0 7 p B b-,t-38-/7-at LS <br /> ar�laQ G✓tLNS c 05 - 000- cc'5 Coo <br /> Property Owner'a Mailing Address Properly Location <br /> �S6S /�Gta Sr N. Govt.Lot <br /> City,State Zip Code 4135-- Phone Number y., Y., Section <br /> A/N X' 5:5-0 3 (circle one) <br /> _� <br /> rr❑aat.Ty ch <br /> of Building eck all that apply) Lot# N; R 17 Eire <br /> T <br /> [Yl or 2 Family Dwellink-Number of Bedrooms N Sub division Name <br /> Block d <br /> ❑Public/Commercial-Describe Use - El City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ®Town of <br /> 111.Type of Permit: Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ER New System ❑ Replacement System ❑ TreatmentEolding Tank Replacement Only 12: ❑ Other Modification to Existing System(explain) <br /> B. ❑Permit R...4 ❑Permit Revision ❑ Chan_eeofPlumber ❑Permit Transfer[o New List Previous Permit Number and Data Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS stem/Com onent/Device: (Check all that apply) <br /> J9 Non-Pressurized In-Giromd ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in..£suitable sea ❑ Mound 124 in..£suitable..it <br /> ❑Holding Tank ❑ er Dispersal Component(explain) ❑Pretreatment Device(explain) __ <br /> V.Dis ersaVTreatm t Area Information• <br /> Design Flow(gpd) esign Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 6D0 -7 �f7 86 N let <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units p o'g o <br /> ew Teaks Exstuig Tanks w e v y -' b A y <br /> y 0. et <br /> Septic or Holdung Tank <br /> Dosing Chamber A dr0 ��lf w X <br /> VII.Responsibility S atement-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 /> /z/�l� y <br /> Plumber's Address(Strad,City,State,Zip Code) <br /> pt 7760 w 3S We-kf{z/ L✓1 S�/84 3 <br /> VIII.County/Department Use Ont <br /> Approved El Disapproved Permit Fee ((��77 Dale Issued Issuing Ag tore <br /> ElOwner Given Reason for Denial S 3,2JC`aZ ,3, ,fst .II <br /> IX.Conditions of Approval/Reasons for Disapproval ,'11,1,1YVn— <br /> ECE E <br /> AWvch to complete plain for the system..it submit b the Courdy ady on paper int less than 81 1 s 2011 g <br /> SBD-6398(R.01/07)Valid thru 01/09 BURNBTT COUNTY <br /> ZONING <br />