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County <br /> Industry Services Division i31Arri <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> 4SPs,. � P.O.Box 7162 /� <br /> i .r Madison,WI 53707-7162 <br /> Sanitary Permit Application State I ransaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govelmnental unit <br /> is required prior to obtaining a sanitary permit Note:Application forms for state-owned POINTS 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 7 4Gy <br /> purposes in accordance with the Privacy Law,s. 15.04(p(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# yo-ib- X31.5'D<--a'O.� <br /> 30,.a_ <br /> T , ka�.sC p 7, o �oiseoo <br /> Property Owner's Mailing Address Property Location <br /> .5 �1 Xs A)/4�� �V 2 Govt Lo[ <br /> City,State Zip Code Phone Number <br /> � <br /> ;� '/., Section ti /n/f/ s /O1 �S7-v!/Y' 9.4 74; (circle one <br /> [I.Type of Building(check all that apply) Lot# <br /> T N; R 16 Eoo <br /> I or 2 Family Dwelling-Number of Bedrooms3 Subdivision Name <br /> Block# <br /> ❑ <br /> Public/Commercial-Describe Use <br /> ❑ City Of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> V-3/a , y Er Town of CorlelAn <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System J0 Replacement System ❑Treatment'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 Expitation Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> iso 7 G4.1 a 41, 6-' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> d <br /> New Tanks Existing Tanks U �_ v " .N <br /> Septic or Holding Tank <br /> Dosing Chamber oo ell <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature l/ MP/MPRs Numbe7!,'/'s7mmes',P hone Number <br /> G/e-le 114r le_. j �� �+' —6S—i (a4—�/.f 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 74 o <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Age St a[ur <br /> Approved ❑ Disapproved S po 2 <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D ROSE <br /> Attach m b <br /> complete plans for the system and so to the County only on paper not less than 8 IR x 11 inches' a Q Z�'S <br /> CS7�L >� <br /> SBD-6398(R0313) BURNETTCOUNTY <br /> ZONING <br />