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County <br /> �mmerce.wi.gO Safety and Buildis Division ngEu <br /> 201 W.Washington Ave.,P.O.Box 7162 Sanity Permit Number(to be Gilled in by Co J <br /> M Madison,WI 53707-7162 52/ 0/ <br /> Itiam sin State Transaction Number <br /> Sanitary Permit Application <br /> In secordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obmining a sanitary permit. Note: Application forms for state-owned IN <br /> are project Address(if different than mailing address) <br /> submitted m the Department of Commerce. Personal information you provide rosy be used for secondary -3 0 {39 011 n e r V 0. <br /> ees.m accordance will the pm'a Law,c.15.04(1(m),Stats. <br /> Parcel .3z — q/ $ ' ,3000 <br /> L A tication lntormation-please print All Information � O 3d <br /> property Owner's Name <br /> /cty1 L k /-H o d property Location <br /> property Owner s Mailing Address Govt-Lot <br /> 7`/ G�/ Yj Ja e✓ a <br /> A . <br /> Plane Numbs ---y section orb <br /> Zip Code (cycle one <br /> City,StateR �/� E o <br /> SS`Y`f J T 4/ N; <br /> area/G/ n Potrlc m^/ Lot# <br /> deck aU that apply) Z I } W !�'k7'22 Subdivision Name p <br /> IL Type of Building T 'S Rwwl6W f 10-y <br /> Q�1 or 2 Family Dwelling-Nnrnber of Bedrooms�— Block# <br /> \ytog❑City of <br /> publr/Commereial-Describe Use 0 Village of <br /> CSM Number fw r JS <br /> ❑ <br /> State Owned-Deauibe Use <br /> Town of <br /> III.Type of Permit: (Check only one box an Ime A. Complete tine B if apptipble) ❑ Other Modificatimt to Existing System(explain) <br /> A. Replacement System ❑To stment/Holding Tank Replacement Only <br /> q New System <br /> List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ❑PermitTransfer to New <br /> B. ❑Permit Renewal ❑permit Revision Owner <br /> Before Expiration <br /> IV.T of POWTS S stemlCom ei Mevice: Check all that a <br /> ON <br /> Non-Preesuized)n-Grormd ❑� �In-Grou.d UM-Grade 11 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑pretreatment Device(explain) <br /> ❑Holding Tank ❑Other Dispenal Compommi(explain) <br /> l Area proposed(at) System Elevation <br /> V.Dix ersalfl'reatment Af)rea btformation: Dispersal AreaRequl'ed(at) Dispersa� /S �!/• p <br /> Design Flow(gpd) Design Soil Application Rate(gpdad /y <br /> 3® 9 Total #of Ivfamufaclrirer U U ,� <br /> Capacity in Gallons Units <br /> VL Tank Wo Gallons `R R <br /> 6 c3 a <br /> New Tanks Ex s Tmks <br /> Septic a Rnlding Tank 900 <br /> Dowing ber <br /> ¢scum¢responsibility for installation of the POM'Sls�lo pRs NumbuMld Business phone Number <br /> tM <br /> VIL gesponsibitity Statement-I,the underai Plunbera Signature <br /> Plumbers Name(Print) '/ g 1$ & <br /> ,e.a/C wo, s lz a /T <br /> Plumber's Address(Street,City,State,Zip Cade) <br /> x(7760 N�- <br /> �-4W-e" yf sr /r9-7 <br /> VI Corm /De utmrmt Use Odpermit Fee Date Issued Issuing A rgnuture <br /> Approved ❑DisapProved $ Z/y)d 1r1'i�,O r05 <br /> ❑Owner Given Reason Denial �f ns �� <br /> IK Conditions of APProvallReasmrs for DisapProvd aU1L0� 5a.U40 ,�1/ ] <br /> /,ipTef: FkOr"I was axe 8*1/ QPfn'6 `j/r� �.; !. <br /> D0a/gs 16 i5xtsixot JWt C"evw FidM <br /> "I Ay <br /> Altacl to e¢mpkte plain fsr the sysnu aM svbon is the CwrrtY only an _ Inrt1um 81a x111rches tabs <br /> BURNETT COUNTY <br /> ZONING <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />