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lre 'tti County <br /> Industry Services Division 13H,^r f f— <br /> ;. 1 "rl�,',,ti 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P P.O. Box 7162 Cq�/t fes,,f^ <br /> Madison, WI 53707-7162101 <br /> J 1 T T(Js�n�l <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),W is.Adm.Code,submission of this fonn to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application fours 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 a 7 31Y.Sr <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. <br /> L Application Information-Please Print All tnformation C'onrl�/S L/c /fid <br /> Property Owner's Name Parcel# yJ_/`_;3(v-S 01.1- <br /> O� Hh 07_GAO <br /> Property Owner's Mailing Address Property Location <br /> 1 / (O • 41,, ReAl Govt.Lot <br /> City,State Zip Code Phone Number <br /> /, /., Section 36 <br /> -e,flL s t<-e/ L(l _5- fQy 3 /S JLcircle one) <br /> R dV <br /> [I.Type of Building(check all that apply) Lot# T NO N; Eor <br /> 1 or 2 Family Dwelling-Number of Bedrooms 0 Subdivision Name <br /> Block# <br /> ❑Public/Cotmnercial-Describe Use _—_ ❑ City of <br /> ❑State Owned-Describe Use ryt <br /> CSNI Number ❑ Village of <br /> 21 Town of 0eC11C/a✓7 LP <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑ New System Replacement System ❑TreatmenUHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑PennitTransfer 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 Arca Requir=d(sf) Dispersal Area Proposed(sl) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o v <br /> New Tanks Existing Tanks :° <br /> 4 o d E ll <br /> 4 U in y rn k. 0 a <br /> Septic or Ifolding Tank ot <br /> Dosing Chamher <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature /l MP/MFRS Number Business Phone Number <br /> /2/e-/�f_ 4f!�vg&1 / l /�` �l S�s-/ lis=BGG - y/s 7 <br /> Plumber's Address(Scree,City,State,Zip Code) <br /> o ,�.... 3,5`w�6s�-rte a✓�'�5`�3 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee 00 Date Issued Issuing Agent i ture <br /> ❑ Owner Given Reason for Denial 3-, <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> � ECEOVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IP-x l l i hes size OCT 11 2016 <br /> SBD-6398(R0313) BURNETT COUNTY <br /> ZONING <br />