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County <br /> Industry Services Division u r <br /> ® tt 1400 E Washington Ave Sanity ermit Number(to be filled in by Co.) <br /> °. sps,, r P.O.Box 7162j��Zl Ill <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application state Transaction Number J <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 fors for stale-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 Y7Y7 <br /> u oses in accordance with the Privacy Law,s. 15.04(1)(m),Stats. :? <br /> 1. Application Information-Please Print All Information 431eew' _r.41Aa vkl <br /> Property Owner's Name Parcel# <br /> ar`ele .ye_l y-/8�.S"CV-4,_ <br /> Iqr it e 7 k e 1A P-le -64,3 — 0.43epp <br /> Property Owner's Mailing Address Property Location <br /> spa s ,? A ft Govt.Lot 3 <br /> City,State Zip Code Phone Number y, A, Section If <br /> Sd. - (circle one <br /> 0sktl.04JA 4 T y0 N; R /4 Eo <br /> IL Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms_� Subdivision Name <br /> Block# <br /> ❑ Public/Commercial-Describe Use ❑ City of <br /> CSNI Number ❑ Village of <br /> El State Owned-Describe Use <br /> Y. <br /> 1 <br /> 1 P p Town of .fli7V <br /> [lL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `� ❑ New System R Replacement System ❑ TreatmentiHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision List Previous Permit Number and Date Issued <br /> ❑ Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Com onent/Device: Check all that a I ) <br /> Non-Pressunzed 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 Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> /S D . 7 Seo 3)1 `13. d <br /> VL Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units v <br /> New Tanks Existing Tanks L ^� <br /> Septic or Holding Tank /QS"p /p�f"p ..L n r•'y'I rCrp,¢®� <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's <br /> Signature j/ MP/MPRS Number Business Phone Number <br /> IF/GIG ]1/D �C I n <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VRI.CountylDepartment Use Only <br /> Approved ❑ Disapproved PermitFee Date Issued Issuing Agent Sigvq <br /> ElOwner Given Reason for Denial $ �J 7:/ ID <br /> IX.Conditions of Approval/Reasons for Disapproval IDECEOVE <br /> I n OCT 0 1 70A 0 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/:x 11 Iche, size <br /> Of <br /> BURNETT COUNTY <br /> ZONING <br /> SBD-6398(R0313) <br />