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�,genxctf:i� County <br /> Industry Services Division <br /> S = 1400 E Washington Ave 5�,;�y permit N in by Co.) <br /> P S P.O. Box 7162 r <br /> Madison,WI 53707-7162 Y� <br /> Sanitary Permit Application State Transaction Number <br /> In 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 POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15. 1 m,Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address property Location <br /> Govt.Lot <br /> City,State Zip Code Phone Number /,,C E '/,, Section <br /> e r (circle one) <br /> T3�N R)� Eo0 <br /> H.Type of Building(check all that apply) Lot# <br /> A,or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑State Owned-Describe Use ❑City of <br /> CSM Number ❑ Village of <br /> �f Town of Irl e e <br /> III.T of Permit: Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ❑Replacement System ❑ TreatmentlHolding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal El Permit Revision El Change of El Permit Transfer to New List Previ Permit Number and Date Issued <br /> Before Expiration Plumber Owner CN f g739S' S�tft a339,Z <br /> T 7-31- <br /> IV.Type ofPOWTS S stem/Com onent/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 Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> d Rate(gpdsf) r '� 19 " <br /> VI.Tank Info Capacity in <br /> d <br /> Gallons Total 4 Of Gallons Units Manufacturer w - <br /> New Tanks Existing Tanks U 0. <br /> Septic or Holding Tank '1 ❑ ❑ ❑ <br /> Dosing Chamber �`� ❑ ❑ ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the PONM shown on the attached plans. <br /> Plurgber's Name(Print) Plumber's Sign re MP/MPRS Number Business Phon Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W12 ty E ,- <br /> VIII.Coun /De artment Use On <br /> Approved ❑ Disapproved Permit Feet^ d Date Issued Issuing Agent Sign <br /> ❑ Owner Given Reason for Denial $ 37J <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Vin E <br /> Attach to complete plana for the system and submit to the 21,7n <br /> County only on paper not less than 8 in x t t inch <br /> SBD-6398(R03/14) BURNETT COUNTY <br /> ZONING <br />