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ON COMPUTER/SCANNED <br />Anaco to compiete plans tot tue system ann sunnut to the county only on paper not less than 8 1/3 s l l inches in size L.J <br />BURNE/yTT COUNTY <br />SBD -6393 (R0313) BONING <br />Industry Services Division <br />County <br />Sct ,^n eff- <br />r <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />p <br />P.O. Box 7162 <br />&0� <br />�1 <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate goverrunental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <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 />7 <br />/ J 5/7G 13& Rd' <br />I. Application Information - Please Print All Information <br />Property Owner's NaIt,ne <br />Parcel #- a y D /,^ <br />b 3 9- 9 <br />Joe U�ha>!1ul° <br />o7-0o_J,- <br />000- 013000 <br />Property Owner's Mailing Address <br />Property Location <br />3W 1.3S" G'N.--h ; to <br />Govt. Lot <br />NE y, $E Section dol <br />City, StateZip <br />Code <br />Phone Number <br />574 �G m Al <br />Ss0-74 <br />61d- �,i� , ya ba <br />ctrcleone <br />T N; R/ E o <br />II. Type of Building <br />yp g (check all that apply) <br />Lot # <br />❑ 1 or 2 Family Dwelling -Number of Bedrooms d` <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑State Owned -Describe Use <br />11 Village of <br />CSM Number <br />p <br />19 Town of j,{/ CSf Not #*6 4 4a rr !i F- ' <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />New System <br />❑ Replacement System <br />Treatment/Holding Tank Replacement Only <br />Other Modification to Existing System (explain) <br />B. <br />Pen -nit Renewal <br />❑Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS System/Component/Device: (Check all that apply) <br />El Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />PrHolding:Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis ersal/Treatment Area Information: <br />Design Flory (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) System <br />Elevation <br />VI. Tank Info <br />Capacity in Total # of <br />Manufacturer <br />Gallons Gallons Units <br />`y <br />` p -p <br />U <br />U <br />New Tanks Existing Tanks <br />c <br />0 <br />Y <br />c, U <br />cn v <br />rn <br />Septic or Holding Tank <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />[� <br />Plumber's Address (Street, City, State, Zip Code) <br />ltie_d s/.,. <br />VIII. Coun /De artment Use Onl <br />Approved <br />Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Agent Signatur <br />❑ Owner Given Reason for Denial <br />J$3767 - <br />IX. <br />IY. Conditions of Approval/Reasons for Disapproval <br />Eur"EIVE <br />OCT 11 2017 <br />Anaco to compiete plans tot tue system ann sunnut to the county only on paper not less than 8 1/3 s l l inches in size L.J <br />BURNE/yTT COUNTY <br />SBD -6393 (R0313) BONING <br />