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ON COMPUTER/SCANNED <br /> syx `�'•R•yr. County <br /> Industry Services Division k N n-e <br /> ?Y: <br /> `�'` b 1400 F_ Washington Ave Sanitary Permit Number Qo be tilled in by Co.) <br /> ` •,SP )-i P.O. Box 7162 <br /> S Madison, WI 53707-7162 1 <br /> X, <br /> Transaction Number <br /> Sanitary Permit Application State/ Q <br /> ht accordance with SPS 38321(2),Wis,AdmC.Code,submission of this torn to the appropriate governmental unit 0W/ R eV.,&W <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> /:3o6 10A. ki o7-6Id d- 4o-i�-a8-s ,S—rao <br /> - v�.9ouo <br /> Property Owner's Mailing Address e Property Location <br /> ) 78y Cl��r SkyRdGovt.Lot <br /> City,State Zip Code Phone Number i� 8 <br /> /, G, Section al <br /> LIV-e6.37ke✓ W.L S11'gIT3 -�/Zy N (circle one) <br /> 11.Type of Building(check all that apply) Lot# T 41`0 N; R /S E or W <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms / g Subdivision Name <br /> Block 01fl <br /> ElPublic/Commercial-Describe Use <br /> ❑ C'ityof <br /> ❑State Owned-Describe Use C'SNI Number ❑ Village of <br /> .® <br /> Town ot' -)Gcksc n <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Re IaeQnent S stem <br /> y p y ❑Trcatirem Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Ph inbei ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Com onent/Device: Check all that apply) <br /> 19 Non-Pressurized fir-Ground ❑ Pressurized In-Ground ❑ At-Gracie ❑ Mound>24 in.of suitable soil u 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(sl) System Elevation <br /> 360 . 7 4I04 S y4/-s- <br /> Vt.Tank Info Capacity in Total k of Manufacturer <br /> Gallons Gallons Units <br /> 7 y 2 <br /> rJ <br /> New Tanks Existing Tanks c v i m <br /> Septic or Holding Tank 7-57a <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 Signature NIP/MPRS Number Business Phone Number <br /> 21 e-leHd leli f ��f� dd SF.r, -7/s 8(6 - y/s-7 <br /> Plumber's Address(Str et,City,State,Zip Code) <br /> 77 3.�— w e6SfYr I .5-'1593 <br /> tV�i1L County/Department Use Only <br /> yy .Approved ❑ Disapproved Permit Fee 90 Date Issued Issuing Ag [ gmatur <br /> ❑ Owner Given Reason for Denial S 3` `� -�-/S <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> q ECENE <br /> w,% 0 2 2M. n <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1 x 7 Alliche m size <br /> BURNETT COUNTY <br /> SBD-6393(R0313) <br /> ZONING <br />