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etiit� County <br /> Industry Services Division gt�rh-eff <br /> ps 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> ps P.O. Box 7162 �(yd� <br /> Madison,WI 53707-7162 L� _ <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.2 1(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 ifterent than mailing address) <br /> the Department of Safety and Professional Scrvies. Personal information you provide may be used for secondary 'l � -L li <br /> purposes in accordance with the PrivacyFJ Law,s, 15.04(1)(m),Stats. i J(V4w`r <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> (56Y-e .n.•Ilev 07-03�a-qlas-- +a S -�cx{-oIaolz <br /> Property Owner's Mailing Address Property Location <br /> v$� Ida.L/ Ct Govt.Lot + _ <br /> City,Stale Zip Code Phone Number '/., Section 014, <br /> Fore. t* G/C MV SSOa.S� (circle one) <br /> T y� N; R /-f Eor® <br /> H.Type of Building(check all that apply) Lot# <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms of Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> El State Owned-Describe Use C��S�M� Number ❑ Village of <br /> Vf ( J l73 <br /> ® Town of S w CJS <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System y El Replacement System X Treatment/Holding 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 /> s— <br /> Before Expiration Owner - <br /> IV.T W <br /> Type of POTS System/Component/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 sod <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> -300 — _ — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks v c a v % � <br /> a U v1 :Z 4 U M <br /> Septic or Holding Tank -7.1r <br /> GYr r„ c <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatu <br /> urA <br /> r <br /> /e /M�P/MPRS Number Business Phone Number <br /> C <br /> � /GIe- /YC� G�q /2e 1/ ..[i SS -7/..f JV 4 is y/S 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ;7 769 O t S uJ c 6 s�-� /-✓1 ,"Y 43 <br /> VIII.Count /De art !t <br /> t Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued t-' Issuing t Signature <br /> ❑ Owner Given Reason for Denial $�!� t d �p���"�J <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEavE <br /> rn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 if es i i-e <br /> BURNETT COUNTY <br /> SBD-6398(80313) ZONING <br />