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.fs;•,� County n <br /> 01 Safety and Buildings Division ! r�('71/� <br /> 'Ir", 0 201 W.Washington Ave., P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 1$P$, Madison,WI 53707-7162 5q /qo-7 <br /> `�r <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 GDUNac7 j Xyl tlj'e rY <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 Scrvies. Personal information you provide may be used for secondary ] u(r ��rFpA" to <br /> n <br /> purposes in accordance with the PrivacyLaw,s. 15.04(I)(m),Stats. to d V J t <br /> 1. Application Information—Please Print All Information F(e4 r t C bvT 5 <br /> Property Owmer's Name Parcel# <br /> 7"fo MCC N San/ 0709a3 71 goiA5o5ooloar o <br /> Property Owmer's Mailing Address /J /) Property Location <br /> Medo v✓ l�rl�c�' Govt.Lot / <br /> City,State ,�/ �/ Zip Code Phone Number -7 , t , a <br /> 1 /V0 J�/l4l N��/�� / r ILL-4, o� /,, Section Q <br /> t/ 5� 3 (�' a 3,o'b ��Y (circle one) <br /> T-37__N; R _Ai7 E ore <br /> Ii.Type of Building(check all that apply) Lot# ' <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> -- 11 City of <br /> ❑ <br /> State Owned-DescrCSM Number //ibe Use_ _ P S9�yrJ ❑ Village of <br /> — <br /> Va �/ (� Town of !—% Q Lfcl/sf+ <br /> III.Type of Permit: (Check only one box on line A. Complete line R if applicable) <br /> A. �New System y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only El 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 /> ❑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(sq Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units p <br /> New Tanks Existing Tanks <br /> v w <br /> W J in H rn u. U 0. <br /> Septic or Balding Tank /SOO OQQ t�/t it <br /> A0�s <br /> Dosing Chamber V Vn/ l <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 Signature MP/MPRS Number Business Phone Number <br /> CL,I/(t✓ AJ-�� 1625 7913 7/S 5fo 5�11w <br /> Plumber's Address(Street;City,State,Zip Code) <br /> /7// 627o" A Ve ILAcot vv S%$5� <br /> VIII.Countv/Dc artment Use Only <br /> fppro <br /> ved ❑ Disapproved Perim <br /> Fee © Date Issued / Issuing Agent Signatur <br /> ❑Owner Given Reason for Denial S �/ 7s-/ I y�/../"� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plass for the system and submit to the County only on paper not fess than a In 1 is <br /> SBD-6398(R. 11/11) OCT 1 1 2016 <br /> BURNETT COUNTY <br /> 7nKu ntn- <br />