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Count? <br /> Safety g CJ 01-4 ,, 77- <br /> 1 <br /> 1-4 W <br /> /�`! .,. Safe and Buildings Division <br /> i�, 1 201 W.Washington Ave.,P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,Wl 53707-7162 <br /> �s51z 29 <br /> Ji <br /> Sanitary Permit Application Sae suction Number <br /> In accordance with Comm. 83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted ro the Deparlm t of Safety and Professional Servies. Personal information you provide may be used <br /> for secondary purposes N rdance with the Privacy Law,s. 15.04(1 m Stats. / / <br /> 1. Application Inform tion—Please Print All Information 7 Iq ,/A+ e O)fW 61;/k <br /> Property Owner's Name 0Parcelo# <br /> er / /e/� <br /> 1 --3&0D-l/- <br /> 011000 <br /> Property Owner's Mailing]Address / / n Property Location f0A b` <br /> 3J /T e Ur [ U/ Cn urc/7 /t C� Govt.Lot 1 <br /> City,State Zip Code Phone Number <br /> / _ %,_Y., Section <br /> h G/l � � W- L!!7T/ rcte one <br /> Il.Type of Building( heck all that apply) 7!Dl Lot# T �N; R =E o� <br /> 1 or 2 Family Dwellin&—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> kv Town of ft,e V <br /> i <br /> 111.Type of Permit: ( heck only one box oe line A. Complete line B it epplozabk:) <br /> A' ❑New System <br /> y .0 Replacement System ❑TreatmentlHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Permit Renewal ❑Permit Revision ❑Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWT5 stem/Com neot/Device: Check all that apply) <br /> 6 Non-Pressor zed In-G bund ❑ Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Ober Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersallyrestme t Arca Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Va 6 spa c �� /0 � �o <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o'g <br /> ew Tanks Existing Tanks c y <br /> 0 <br /> Ed m � � w 5 a. <br /> septic or Holding Tank X mo /�I<Fi`Gu re <br /> Dosing Chamber <br /> VII.ResponsibiBty$ tement- 1,the undersigaed,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' SignaN MP/MPRS Number Business Phone Number <br /> Plumber's Address(S City,State,Zip Code) / <br /> 0 BD,(^ 0 -Sic 11,44'E 'S/2 7 / <br /> V,I�II.Coun /De eat Use Only <br /> a1 Approved ❑Disajpproved Permit Fee Date Issued Issuing A tore <br /> ❑ r Given Reason for Denial a�ei7 c. s1Jl( <br /> IX.Conditions of AltrovaVRemsoos for Disapproval <br /> ECE t:J E <br /> Anach to comphh plane for the system and submit b the County only on paper not leu than a 112 x I I locate In <br /> DEC 13 2011 <br /> SBD-6398(R. 11/11) BURNETT COUNTY <br /> ZONING <br />