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County <br /> Industry Services Division t^I"A e7y <br /> It, D <br /> s P � 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 /1G�/1/)� <br /> $, ' Madison,WI 53707-7162 <br /> ;qj— <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this than 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 `/'7.3 Al <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. a <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Jo�i�t ki�ts —oo�- ciga0o <br /> Property Owner's Mailing Address Property Location <br /> 45's/ )3rd Av,,o N w Govt.Let s <br /> City,State Zip Code Phone Number 9 <br /> h,� /, /<, Section <br /> /Veld dry ti t /�'en N _5 r/l� {circle one) <br /> I[.Type of Building(check all that apply) Lot# <br /> T 3g N; R1s 1 017,9 <br /> t; ,J 1 or 2 Family Dwelling—Number of Bedrooms —r 3 Subdivision Name <br /> Block# <br /> ❑Public/Corunercial—Describe Use <br /> ❑ City of <br /> ❑Slate Owned—Describe Use CSNI Number A 1 7"If ❑ Village of <br /> _..__ u /3 R ,�8 R'Town of L a i-o <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, New System <br /> p� y ❑ Replacement System ❑ TrzannenUl folding Tank Replacement Only ❑ Other Modification 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/Component/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ lvlound<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.Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> G 0 0 ' s, /)oD <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 9 u <br /> New Tanks Existing Tanks d u <br /> Septic or Holding Tank <br /> Dosing Chamber 6dO <br /> V11.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/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 017760 /z/,y Ule%j/y,- 1 -5�y q:93 <br /> VIII.Count y/De artment Use Only <br /> Approved ❑ Disapproved Perintt7fee © Date Issued Issuing Agcnt.igna re <br /> ❑ Owner Given Reason for Denial 5�/ 0 Y <br /> I%.Conditions of Approval/Reasons for Disapproval pp <br /> EC E �V E <br /> tDGc>� %o lllfel-a LZ ��v��✓u�Ks D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IR x 11 to <br /> six 2 <br /> 017 <br /> .01 <br /> BURNETT COUNTY <br /> SBD-6393(R0313) ZONING <br />