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+ 'ht County <br /> tx Safety and Buildings Division r9e <br /> SP NI 201 W. Washington Ave., P.O. Box 7162 <br /> Sanitary permit Number(to he filled in by Co.) <br /> ;y4 `—g Madison,WI 53707-7162 <br /> '�. 558UPJ <br /> air, <br /> Sanitary Permit Application State Transaction Number �QGll <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit .Sz7� J OJOQ / <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 /> o <br /> r in accordance with the PrivacyLaw,s. 15.04(1 m,Stats. <br /> heation Information-Please Print All Information <br /> Owner's Name Parcel k 008- Z/O/-oz-Orro <br /> �eRm�.n6 ERmFlfI 07 _2.38-iK- Q3•noo-a/ro 51 <br /> Owner's Mailing Address Property Location <br /> z q Li u IK ' lZo.9c <br /> te Zip Code Phone NumberCovt.Lot <br /> 1,50 K,�A, Section 01 <br /> l�t� L4K£ l: 111 SK 27) fo51- 7V5- 7-20le one <br /> 11.Type of Building(check all that apply) Lot b T -18 N, R /V E orbV <br /> m l or2 Family Dwelling-Number of Bedrooms Subdivision Name .3/!.'07 G$ <br /> Block k <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 11 Village of <br /> 'Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Y Z Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification m Existing System(explain) <br /> B• ❑ Permit Renewal ❑Permit Revision ❑ Chane of Plumber List Previous Permit Number and Date Issued <br /> Before Expiration g ❑Permit Transler to New <br /> Owner <br /> IV.T e of POWTS S stem/Com onenVDevice: Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade XMound,24 inof suitable soil ❑ Mound<24 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Trestment Area Information: <br /> Design Flow(gled) Design Soil Application Rate(gpdsf) Dispersal Arca Required(st) Dispersal Area Proposed(st) System Elevation <br /> t/go . S 4S0 Oso <br /> VI.Tank Info Capacity in 'total q of Manufacturer <br /> Gallons Gallons Units <br /> New TanksExisni v 9 <br /> ng Tanks m U it _ <br /> Septic Oz ddi =-k <br /> Tao-3o0 ioo0 <br /> Dosing Chamber (cop <br /> 600 <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for'nstallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print)lnet ✓u"S^ d Plumber Signa re MP/MM Number Business Phone Number <br /> a3ya�s <br /> Plumber' 22 CbU t LI ER AD <br /> �Vill.Count e <br /> IRilApproved ❑ isapprove Permit Fee Date Issued Issuing A gnature <br /> Oaf- <br /> D Owner Given Reason for Denial I S 3 75*D60 I' J_Vy zyZ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than a Ill a 11 inc in e JUL 1 <br /> BURNETT COUNTY <br /> sBD•6398(R. I v11) ZONING <br />