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. N <br /> la Safety and Buildings Division County u��E <br /> 201 W.Washington Ave.,P.O.Box 7162 S7iW Numberr to be figed m by Co.) <br /> ° F Madison,Wl 53707-7162 =��Ji{/ICC�I_ <br /> j <br /> Sanitary Permit Application State Transaction Number 11 <br /> 0In accordance with SPS 383.21(2),Wis.Aden Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forts for state-owned POWTS are submitted to Project Address(if different thaa mailing address) <br /> the Department of Safety and Professional Servies. Personal information yen provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15. 1 m,Stars. <br /> I. Application Information-Please Print AN Information <br /> Property Owner's Name Parcel# 07-a 34 q <br /> GL" KjM 1A1,A1t 4D,-C OS'003-0//000 <br /> Property Owncr's Mailing Address' t Property Location <br /> 5Pq 13 go (!V ' Govt.Lott 1 p� <br /> city,state �/ ZZipjC�ode Phone Number y., — v., Section Y <br /> I- 3$ N; R E« <br /> Lot# <br /> II.Type of Building(check all that apply) <br /> I or 2 Family Dwelling-Number of Bedrooms me Subdivision Na <br /> Block# ` <br /> ❑Public/Commercial-Desenbe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> --- "� VTownof <br /> ItL Type of Permit: (Check only one boa on line A. Complete Use B if applicable) <br /> A. ❑New System Replacement System 8 Replacement Y 8 Y ( xP❑TreatrrrertNFloldin Tank R lacement Only Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Phrmber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner if/i r 0 iv / Pea rCG <br /> IV.T of POWTS S tendCom oneut/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑M-C:rade ❑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(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 'f 50 ©r 7 /�h'2.S(o 61'2 9 3g� <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks c y A <br /> a V in R vi ir. O G. <br /> Holding lank x 1 <br /> 61 <br /> 0 ! (JESW� !` <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned ;Rky for installation of the POWTS shown <br /> on the attached <br /> us s. <br /> Plu s Namp(Priot C� PI i s S MP/C/M�/S Number Biness Phone Number <br /> f �/ - ?��S <br /> P s A�Mress(Strect, iry,�hate, Code) <br /> VM.CountyADepartment Use Only <br /> Approved ❑Disapproved Permit Fee D Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ 75't O / - l <br /> U 'Roaditions of ApWaval/Reasons for Disapproval <br /> �� Lirhi►�; 10GtG�0/ :s Gri>Li4aL a z!�' /a" e� Covl+ril/tt►a�to��uP! LeLLse <br /> nD <br /> Attach to complete plans for the system awd submit to the Coanty only oo paper not less than 8 rn x 11' size <br /> JUL 19 2017 <br /> S13D-e398(R. 11/11) BURNETT COUNTY <br /> ZONING <br />