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yam"1 ip i County <br /> Industry Services Division i3r^�n e7`F <br /> $ S1 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> j p$ P.O. Box 7162 �� <br /> Madison, WI 53707-7162 �Q _ <br /> Sanitary Permit Application MatemnsactionNum <br /> � <br /> /b <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Cm✓N f� /`^ber <br /> �V=!V1 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POINTS 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 q a d <br /> purposes in accordance with the PrivacyLaw,s. 15.04(1)(m),Stats. <br /> 1. Application Information-Please Print All Information //4.1 Sc w k /V <br /> Property Owner's Name / Parcel# <br /> t!QY'N �GI7Ne4 o�- od8-d-y�- w-ob-S-fj_a�s <br /> O / YOOO <br /> Property Owner's Mailing Address Property Location <br /> dOO��( NO.>,csfCa� Crf Govt.Lot <br /> Cit/y,State Zip Code Phone Number y, />, Section <br /> L (Ce V1,1A /-P//I/ ?e Lt gSd- 3'IY3 83 GI T ,o N; R (circle <br /> eone) <br /> Il.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms - Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> om <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of .SGo7`f <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Pennit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS Sys tem/Comonent/Device: (Check all that a Iv) <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 Plow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> S� 9d o 171e q y. V <br /> V t.Tank Info Capacity in I otal #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks �.`�, U <br /> .ccd <br /> mV G <br /> Septic or Holding Tank /bQ41 /Od0 <br /> Dosing Chamber 600 6 OU <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 MP/MFRS Number Business Phinte Number <br /> 171e-le- 17d k.n t / // d.lt8! ! 7/5-866. y/S 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7760 t. 3s lti e5s�.� �r sir, 93 <br /> ,Vill.Coun /De artment Use Only <br /> yp Approved ❑ Disapproved Pennit Fee Date <br /> /Date Issued Issuing Agent Signa re <br /> f\ ❑ Owner Given Reason for Denial S 7-�• �/ (O-��—/�p <br /> IX.Conditions of Approval/ReasRns for Disapproval <br /> SIiPcf �� l�raPos«( jedi/Y % *JJ 76' 4e remouel, <br /> JUN 17 7 201 2016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x nah6 in: <br /> BURNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />