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ON COMPUTER/SCANNED <br /> commercemi.9oV Safety and Buildings Division County �? <br /> 201 W.Washington Ave.,P.O.Box 7162 V 4 r n if 7V" <br /> fiseonsin Madison,W153707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> V� <br /> Department of Commerce &SS O <br /> Sanitary fermit Application Stare Transaction Number <br /> In accordance with s.Comm.8321(2),Wi.Aim Code,submission of this farm to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forme for slate-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the PrivacyLaw,a.15. 1 m),Stats. I, <br /> L Applicastiont Wormatiar-Please Print All Intormstioa (p <br /> Property Owner's Name Pared# <br /> Ei/eco Qakrre �+3a�([JI Of0 1430} 4Ps700 <br /> Property Owner's Mailing Address Property Location <br /> ,p S-0I Hit den. Lk e(. Govt.Lot, <br /> City,State Zip Code Phone Number7, <br /> Yy Y., Section <br /> �AH 6ar WZ- Sy 830 7/S- 4%sG-3v 98 T yG N, R (circle one) <br /> IL Type of Building(dieck all that■p ) Lot# <br /> ®l or 2 Family Dwelling-Number of ma �` Subdivision Name <br /> Block# <br /> 0 Public/Commerttial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CS/M Number 0 Village of <br /> \ /_ a a�l Town of OM/L/wwp(. <br /> e �!f <br /> IDL Type of Permit: (Check only one box on lire A. Complete fine B if applicable) <br /> A. 0 New System W Replacemen System 0 Tresummutio ding Tank Rephcemmt Only 0 Odiar Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 PermitRevision 0 ChangeofPlumber OPermitTransfato New Lit Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of PORTS S stem/Can Check all that apply) <br /> [}Non-Pressurized In-Ground. 0 Press In-Ground 0 A6Gmde 0 Mound a 24 in.mf suitable sod 0 Mound<24 in.of euimble soil <br /> OHnlding Task 001her Dispersal ent(cxplam) OPretrumrcnt Devim(explain) <br /> V.Dispersalfrreairrent Area Informs m: <br /> Design Flow(gpd) Design Soil Applicmi Rate(gpdef) Dispersal Area Regained(st) Dipeaal Area Proposed(af) System Elevation <br /> 300 , 7 429 432, <br /> VL Tank Indo ity in Total #of 1 Manufacturer ss <br /> G oar Galkm Units <br /> New Tanks Existing Tanks rR3 g S <br /> CS in <br /> Septic a Holding Tank 7f D 7S"O / We_ .P <br /> Dosing Clamber .0-00 son / 1 7-+-1 ..(� <br /> VII.Responsibility Statement-I,the uni¢reigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rte-k- d7 4/s-'s <br /> Plumber's Address(Street,City,Stare,Zip Co, ) <br /> x47760 3S e5sfra w1 Sga53 <br /> VII mor /De arlment Use Only <br /> Approved 0Disapproved Permit Fee ate Issued Ieeuing igmamre <br /> 0 Owner Given Reason f %5/�� '1 JVDenial S ) LY r07 <br /> IX.Conditions of Approval/Reasons fri r Disapproval <br /> Soil Absoo6ion Cell ReXacemen6 Only <br /> Amchto m.plel e plarefarthe ayesm and submit mthe Cmmyenlym papermtls thsea r2 all" <br /> f1f1t� <br /> SBIM398(R.01/07)Valid thin 01/09 JI, JUL 1 ` <br /> .a Wil <br /> L� BURNETT COUNTY <br /> ZONING <br />