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� /.3 Q <br /> f r A Industry Services Division "r✓I <br /> ��F ai p• 1400 E Washington Ave SaniEary Permit Number(to be tilled in by Co.) _ <br /> P.O. Box 7162 <br /> a� > <br /> SJRN-'.2 22g <br /> 4s. t �I�s Madison, VUI 53 70 7-71 62 <br /> Sanitary Permit Application State Transaction Number <br /> fn 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 PO4VTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),S tats. I Y <br /> I. Application Information—Please Print A-HInformation <br /> Property Owner's Name 1 ,� �+ Parcel# <br /> Vv 4 r o7-v7�a_1' ya-� <br /> 006-3�- <br /> 6 —. 01 xecv <br /> Property Owner's Mailing Address Property Location <br /> AY13 410 a, 4vt Govt.Lot <br /> City,State �1 Zip Code Phone Number y, V4, Section 3& <br /> �5ceoI a LAl -Ca (circle one <br /> 11.Type of Building(check all that apply) Lot T �y N; RA_Eo�V <br /> 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number p Village of <br /> I�Town of O a IC 1A a! <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only El Other N[oditication to Existing System(explain) <br /> B. Permit Renewal ❑Permit Revision El Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.lygia.of POW ITS.S stem/Com ponent/Device: (Check all that apply) <br /> Q l`Coa f�esurized In-Ground ❑Pressurized In-Ground ❑ ❑ Mou <br /> nd ound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> E{olaai�Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VDis'`ersal/Treatment Area Information: x. <br /> Design Flow(gpd) Design Soil Application Rate(gpdsfl Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units U D <br /> New Tanks Existing Tanks 9 o a Q _ a <br /> c m � <br /> U cn ti cn w t 7 a <br /> Septic or Holding Tank 05-0 7S0 Or/O to eSYr <br /> Dosing Chamber_ j <br /> VI1.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the PObVfS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br /> Plumber's Address( treet,City,State,Zip Code) \ <br /> 76 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit <br /> Fee Date <br /> Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial " <br /> 1K.Conditions of ApprovaUReasons for Disapproval <br /> nee+ t <br /> Attacb to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inc s in st <br /> Burnett C our'tty <br /> Land-Services Departrrjef, <br /> SBn-Ft�erRnit11 t om(—F►C1 %:-z <br />