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,?County <br /> Industry Services Division j3f,, rvt <br /> fit; D5 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> `' Ps i P.O. Box 7162 ��`��/6/�� <br /> 'h,,a t Madison, WI 53707-7162 <br /> Stale Transaction Number <br /> Sanitary Permit Application <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 —7 of 147 GCrGCr nc� E <br /> purposes in accordance with the Privacy Law,s. 15.C4(I)(m),Stars. _ <br /> L Application Information—Please Print All Information <br /> Property Owner's Name Parcel# y0„J�-31-s- eS <br /> Rand Sn s o7-btu~�- <br /> _ aeS- oJJof'o <br /> Property Owner's M iling Address ,t n Property Location <br /> -?&d at YO if l� i4 A S. /T P/ Govt.Lot <br /> City, <br /> State Zip Code Phone Number /, 'b, Section 5_1� <br /> G=d f )JI/ -s.�y-3.S 6,s'f--33�t- �iyS� (circle one) <br /> It.Type of Building(check all that apply) Lot# T_ '(-/&? N; R 46 E ot(99 <br /> ❑ I or 2 Family Dwelling—Number of Bedrooms ?A,,* 3— Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> L21 S—,A ITown of l' &klAn o(' <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Replacement System <br /> y ❑ Treatment/Holding Tank Replacement Only ❑ Other Madilication 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/Corn ponent/Device: (Check all that apply) <br /> ❑ Nod-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> 9 holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdstj I Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> Sao <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks U <br /> Septic or Holding Tank GO p ODp / W1-eJ e✓ t/ <br /> Dosing Chamber �1 <br /> VII.Responsibility Statement- I,[he 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 /> Plumber's Address(Street,City,State,Zip Code) <br /> III.Coun /De artment Use Only <br /> Approved ❑ Disapproved <br /> Permit Fee Date Issued Issuing Agent Signa e <br /> 2 <br /> El Owner Given Reason for Denial $ v 7��D <br /> IX.Conditions of Approvat/Reasons for Disapproval <br /> n <br /> E' EWE <br /> Attach to complete plans for the system and submit to the County only on paper not less than s / x 1 the 0 2017 <br /> 12) <br /> BURNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />