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County <br /> Industry Services Division <br /> 1400 E Washington Ave n <br /> S P P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI53707-7162 _'03_-15 <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 Services.Personal information you provide may be used for secondary ' D 677 <br /> puiposes in accordance with the Privacy Law,s.15.04 1 m,Slats. Z Z f-o I Nu <br /> +It+ L cLn� <br /> L Application Information—Please Print All Information �D <br /> Property Owner's Name Parcel# 07 pD —Z—59—/ <br /> 6le'll Al <br /> Property Owner's Mailing Address )1 Property Location <br /> Z R) Govt.Lot / <br /> City,State Zip Code Phone Number —r— / Section <br /> �Q (circlo <br /> /� �{/ ✓7 Lot# T�1�N; R��E or� <br /> IL Type of Building(check all that apply) <br /> 191 or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> (Town of 11qj11r,41 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)ICI <br /> A_ New System ❑Replacement System ❑TreatmenUHolding 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 Owner <br /> IV.Type of POWTS S stem/Com onent'Device: Check all that appl <br /> IN 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 /> 17 ©, (�y3 G�So �5/ <br /> VI.Tank Info Capacity in Total #of Manufacturer �? <br /> Gallons Gallons Units = $ <br /> L <br /> L M <br /> New Tanks Existing Tanks o <br /> U in rn iE C7 D <br /> Septic or Holding Tank /22 <br /> Dosing Chamber �•�JC-/ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans <br /> Plumber's Name(Print) J Plumber's Signature MPAVRS Number Business Phone Number <br /> oe <br /> Plumber's Address(Street, <br /> City,Sta ,VIII.Court /De artment Use bnly <br /> X Approved ❑Disapproved Permit Fee Date <br /> /Issued Is in ent Si <br /> ❑ $ lop— <br /> Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reaso s for Disapproval <br /> nni <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 telm <br /> is <br /> ° Burnett County <br /> land Services Department <br /> 3UU1 <br /> SBD-6398(R.08/14) <br />