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Co <br /> Safety and Buildings Division !/ <br /> P M201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> Ss <br /> Sanitary Permit Application State Transaction Number �) <br /> In accordance with SPS 38321(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 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(I)(m),Stats. 1017 T ldp^ lk <br /> I. A lication Information—Please Print All Information / <br /> Property Owner's Name Parcel# <br /> e_ CO/�+Ne1 07-07-Z 7- Oa WeOlyra* <br /> Property Owner's Mailing Address Property Location <br /> 1-38Z2! CSG IU et Govt.Lot � -7 <br /> City,State / Zip Code Phone Number y4, Y,, Section <br /> IG tallle SSI2 9 .dID� T_��N, R�4Eo>� <br /> 11.Type of Building(check all that apply) Lot# , <br /> ,V1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use Cl City of <br /> CSM Number ❑Village of <br /> ❑ <br /> State Owned-Describe Use _ <br /> KTownof 1 1cl2 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A.. ❑New System ❑Replacement System I"Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> ❑Chan List Previous Permit Number and Date Issued <br /> B. ❑Permit Renewal ❑Permit Revision Change of Plumber ❑Permit Transfer to New ((�� <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> M:Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suit'de soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersai/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o q <br /> w u <br /> New Tanks Existing Tanks o <br /> Septic or Holding Tank /isQU O� NA/1,►rCh�O <br /> Dosing Chamber VV <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) / Plum ignapw MP/MPRs Number Business Phone Number <br /> 05� D hC1Cr //��G��%�r 8S�g5 7i5-5�-opo Z <br /> Plumber's Address(Street,City,State,Zip Code) / <br /> Z 7ZZv snlCJ r/��ib57�0" 1nl i <br /> VRI.Countyll3epartment Use Only <br /> Approved L1 Disapproved Permit Fee O Date Issued issuing Agent Si tore <br /> ❑Owner Given Reason for Denial S t7 ��O� [,� + /5 I(Q <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> FF� EQEIVEE� <br /> Attach to complete pisco for the system and submit to the County only as paper not less than 8 1121f1 Inch n <br /> JUN 15 2016 <br /> SBD-6398(R. 11/1 1) <br /> BURNETT COUNTY <br /> ZONING <br />