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yt }i`• County <br /> Industry Services Division tti v il 1 <br /> 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 .j�-2��Qo 33 <br /> Madison, WI 53707-7162 <br /> Stat <br /> Sanitary Permit Application eeTransactionyNumbe <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit `�U'��1 �P✓e•"V` <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. ��/ <br /> L Application Information-Please Print All Information Aµ-Sl'r� �/G I�Gt <br /> Property Owner's/Name n Parcel k o7 <br /> C��fN <br /> Property Owner's Mailing Address Property Location <br /> ,-5-J, v <br /> J,� '^e U sst- Govt.Lot <br /> City,State Zip Code Phone Number i y, Section <br /> 1� lOtfSdti✓ (circle one <br /> TN; R <br /> � S37o �d�' adS-373 / �Eo <br /> tr <br /> If.Type of Building(check all that apply) Lot# <br /> 'Ior2Family Dwelling-Number ofBedrooms Subdivision Name <br /> Block# <br /> ❑ Public/Cotnmercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ village of <br /> 19'fown of M e'ell 0 h <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Ar Replacement System ❑ Treatment/I[ohting Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 11 Permit Renewal El Permit Revision ❑ Chane Permit Transfer to New List Previous Permit Number and Date Issued <br /> Charge of Plumber El <br /> Before Expiration Owner <br /> IV.Type of POWTS Sys tem/Comonent/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(st) System Elevation <br /> 36a 'y ��y s-yo 9�,� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o ❑ v <br /> New Tanks Fxisting Tanks v m <br /> 0 <br /> c: U v y 00i�. U i <br /> Septic or Holding Tank Ci�0 <br /> O / x <br /> Dosing Chamber <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 MP/MPRS Number Business Phone Number <br /> /2 I cde- e J 7/ Q15-7 <br /> Plumber's Address(S et,City,State,Zip Code) <br /> )7 7/0 t,. 3,_-!r— <br /> VIII.Cour /De art ent Use Only <br /> Approved El Disapproved <br /> Permit Fee Date Issued Issuing Agentnigna <br /> S <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECE0VE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 Ill met ins <br /> BURNETT COUNTY <br /> SBD-6398 (R9313) ZONING <br />