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oaeu`r'kvr <br /> R+ l ' Q° Safety and Buildings Division County e:// <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> R" Madison,WI 53707-7162 <br /> Sanitary Permit Application Stater sacti ,mber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit ✓kA/onN1P.ct� <br /> is required prior to obtaining a sanitary permit. Note:Application fortes 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 107,,9 N <br /> purposes in accordance with the PrivacyLaw,s.15.04 1 m,Stats. / J 1 r <br /> I. Application Information—Please Print All Information 11 /p04 <br /> Properly Owner's Name Parcel# o a <br /> �- �-a 3 <br /> a,i8-ate <br /> o � Q N <br /> l a � I , A- A 0 �- ©06 - o ion <br /> Property Owner's Mailing Address Pro ertyhocation <br /> �( <br /> r c— /q- Govt.Lot , <br /> ity,State Zip Code Phone Number , <br /> " ' �{ /., %., Section <br /> /fig/e-CJODG/ /v :_ _/0 (. ctrcleone <br /> T N; REorb <br /> R.T e of Building(check all that apply) Lot# <br /> or 2 Family Dwelling—Number of Bedrooms —Z —3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> r-- <br /> ❑City of C__ <br /> El State Owned-Describe Use CSM Number ❑Village ofI <br /> 7TOwn of ,, f <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) " <br /> A. Aew System ❑ Replacement System y p y ❑ Treatment/Holding Tank Replacement Only ❑ 'Other Modification to Existing System(explain) <br /> B. El Permit Renews( El Permit Revision El Change of Plumber ❑Permit Transfer to New <br /> 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 Rme(gpdsg Dispersal Area Required(so Dispersal Area Proposed(sg System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units `'' o '� v <br /> New Tanks Existing Tanks o u <br /> a. U in ti v. 0 P <br /> .upriser Belding Tank <br /> Dosing Chamber <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 IBusiness Phone Number <br /> G) A-- k (4 Fs�a/,1;7 1 /W)0�& 1 z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ,4 c> 5/V s-//'e n� C<J� S'lQ 7s2 <br /> VI I.CountylDepartment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing A nature <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval �^ <br /> 1Jo>E. 7hL Sr�c aF the 41 ++5 YnK ff nlorAt* e rq�/tw dire D '(lv`!' <br /> AE F*Acx*JJt:, of rifle ftJoa! l ka, <br /> �i MAY 222012 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 101, ches in size <br /> BURNM COUNTY <br /> ZONING <br /> SBD-6398(R. 11/11) <br />