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_'.►3 County <br /> /;` �',. Industry Services Division 9C.f n 1.i� <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> S P.O. Box 7162 QQ I L <br /> Madison,WI 53707-7162 .5 &14 <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 0000,E e d"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 3 O q ju <br /> purposes in accordance with the Privacy Law,s. 15.04(t)(m),Stats. _ <br /> L Application Information-Please Print All Information / n tt!C led <br /> Property Owners Name Parcel# _ <br /> i4e // ©� Ft1 07- 03.1 G osO <br /> OVy• t, <br /> Property Owners Mailing Address Property Location <br /> lx( r ( #S.t A V/e w /J✓' Govt.Lot <br /> City,State Zip Code Phone Number ''/a, Section 13 <br /> V <br /> /4 �e V (�Ct A(/(/j/ S-S/ N 9Sa- lyn-Y4i ,G (circle one) <br /> "1' N; R /6 E ore <br /> II.-type of Building(check all that apply) Lot if <br /> Q <br /> 521Subdivision Name I or 2 Family Dwelling-Number of Bedrooms ( <br /> Block k c -�- � -- <br /> ❑Public/Cormnercial-Describe Use <br /> -- ❑ City of <br /> ❑State Owned-Describe Use C�SIvI Number �] ❑ village of <br /> -- V. �� I • '✓1� <br /> Town or .SW/Sum <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System ® Replacement System ❑Treatinent/Holding Tatrk 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 Dale Issued <br /> Before Expiration Owner <br /> [V.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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> (oe o . -2 Y6 y Fby qy.e Y.- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> d <br /> Gallons Gallons Units � � U 3 <br /> New Tanks <br /> ExistingTanks <br /> c.0 c-n tiU a <br /> Septic or Holding Tank 141.�Fv I /�Sa <br /> Dosing Chamber 75"0 17.l a <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 Nmnber <br /> /ZI e./[ 1110,4/--/n 5 Z -•r� >� d ."_f-1 his "/,5-7 <br /> Plumber's <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77 0 0 ?4/t 3s— w cds>`�� /,vj SYS93 <br /> VIII.Coun IDe artment Use Only <br /> Approved ❑ Disapproved Permit Fee 9 p Date Issued Issuing Agent Signaatr <br /> ❑ Owner Given Reason for Denial • S- / .3 -Z.+ '/� <br /> [X.Conditions of Approval/Reasons for Disapproval <br /> np ECEIVE nn <br /> Attach to complete plans for the system and suhmit to the Counr only on paper not less than 8 in x V <br /> inch in sMAR 16 2016 <br /> BURNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />