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> urt�titi County <br /> Industry Services Division �urnK7`t <br /> 1400 E Washington Ave Sanit Permit Number(to be tilled in by Co.) <br /> Ps P.O. Box 7162 -'7�3�cj <br /> t Madison, WI 53707-7162 <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 govemrnental unit 4 5z /3 /0 <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(1)(m),Stats. <br /> 1. Application Information-Please Print All Information Ga 6 !e 3 /ZaP <br /> Property Owner's Name Parcel# y 1, <br /> Property Owner's Mailing Address Property Location <br /> 3 t'' Govt.Lot 2 <br /> City,State Zip Code Phone Number ',�, '/., Section 3 3 <br /> W,e66 La/fie w� 13y83 a la S(-a 5S 7 9 3 le 1� ao N. R_[ e) <br /> lI.Type of Building(check all that apply) Lot# <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms J A *-3 Subdivision Name <br /> '7 3Block# ,� e <br /> Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> ® Town of 0A./G/.t..r VR <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' JZ New System ❑ Replacement System y p y ❑ 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 /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 4 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(st) Dispersal Area Proposed(sf) System EI vation <br /> 7Sb . 7 /33* i3J g 9�! 9l. 7 9d <br /> Vl.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v <br /> New Tanks Existing Tanks o v t5 <br /> Septic or Holding Tank /r&S /SGS Z✓(CSC✓' X <br /> Dosing Chamber <br /> VIL Responsibility Statement- 1,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 /> /(iet k W& kt•, S 1 12",e �oJSBs / 7/S e4l�6 - Z11/3'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7'7 N. .?S W-e.6,s <br /> VQI.Count /De artment Use Only <br /> ❑ Approved ❑ Disapproved Permit Fee <br /> ` Date Issued issuing rgnatucy <br /> ❑ Owner Given Reason for Denial S 3/,7 4 gi Ai it i <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> INE <br /> Attach to complete plum for the system and submit to the County only on paper not less than 8 112 x 11 Inch o <br /> SBD-6398(R0313) BURN COUNTY <br /> ZONING <br />