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, ' ' `:• Industry Services Division County�Gt vn <br /> y f L_ S'PSr;i 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 DC7, <br /> Madison, WI 53707-7162RP <br /> &W4 <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 <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 Cr a,,,-7 <br /> urposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �+ <br /> L Application Information-Please Print All Information Cr+t// C l Ov <br /> Property Owner's Name <br /> Parcel# -L41—>4,_'3b-1y b cl <br /> Property Owner's Mailing Address at 6oU D(/Odb <br /> �.y/ ,�} Property Location <br /> 9 1 l0 f h f G1"`�S /T V Q Govt.Lot <br /> City,State Zip Code Phone Number ,A f� 347 <br /> �L�A, Section <br /> JY pet u {9'1 /✓ (circle one <br /> 1L �ll.Type of Building(check all that apply) � Lot# E <br /> T N; R <br /> 111 or Family Dwelling-Number of Bedrooms ( Subdivision Nante <br /> BFick# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSIvI Number ❑ Village of <br /> U Al` P / ly 13 Town of ,S�t 6V ISS <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> A. <br /> ❑ New System Replacement System ❑TreannendHolding 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 S stem/Com onent/Device: Check all that apply) <br /> XNon-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(so Dispersal Area Proposed(st) System Elevation <br /> Low a S 1 ?GD fan 7 3. s— <br /> VI.Tank Info Capacity in Total #of Manufacturer ti <br /> Gallons Gallons Units N c <br /> New Tanks Existing Tanks <br /> b v n <br /> Septic or Holding Tank Mea leew X <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Countv/De artment Use Only <br /> t <br /> pproved ❑ Disapproved Fspo! <br /> t Feeee+ Date Issued Issuing Agent Signa re❑ Owner Given Reason for Denialw• % -20- 1 6 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> dkL <br /> np ECEPVE �nj <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x l I i hes size SEP 2 0 2016 <br /> SBD-6398(110313) BURNETT COUNTY <br /> ZONING <br />