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ON COMPUTERISCANNED <br />/ 'J ; - <br />_z -„a, <br />Industry Services Division <br />County <br />all, ✓ n e <br />Sanitary Permit Number (to be tilled in by Co.) <br />t4� <br />1400 E Washington Ave <br />P.O. Box 7162 <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 governmental 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 />y'r 4 <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />4GaN.ily+A11 ✓, vP <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # D7- 039 •1- <br />P'. ?qy 4 (2h Ai <br />ns- 009- 05';w <br />Property Owner's Mailing Address <br />Property Location <br />d b d H'1 a e:P, s, h l7aP. <br />Govt. Lot al <br />/, y,, Section d <br />City, State <br />Zip Code Phone <br />Number <br />L �b �r'7t t /V <br />y 6Sy ti <br />7 y- 8Sa - /835— <br />(circle one) <br />T y � N; R � E o(� <br />II. Type of Building (check all that apply) Lot <br /># <br />Subdivision Name <br />,® 1 or 2 Family Dwelling — Number of Bedrooms 3 <br />y <br />Block <br /># <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned - Describe Use CSM <br />❑ Village of <br />Number <br />2ITown of <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 />❑Pennit Renewal <br />❑Pen -nit Revision <br />❑ Change of Plumber <br />Pennit Transfer to New <br />List Previous Pennit Number and Date Issued <br />Before Expiration <br />FO ner <br />Q <br />IV. Type of POWTS System/Component/Device: (Check all that apply) <br />Non -Pressurized 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) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (st) <br />System Elevation <br />Z -1S"12 <br />. 7 <br />6q3 <br />el. 9 8 <br />93.3 <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />V <br />a <br />v o <br />:? <br />ti <br />New Tanks <br />Existing Tanks <br />o <br />a U <br />f <br />n <br />Y <br />rn <br />R a <br />u U a <br />Septic or Holding Tank <br />l9 U d <br />/OOr/ <br />I <br />s/L�LX, <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 />_vKW1'-Z/is7 <br />Plumber's Address (Street, City, State, Zip Code) <br />// c <br />)'776e, /Y � w t ,�W -eAr l.,- WT <br />VII. County/De artment Use Only <br />Approved <br />El Disapproved <br />Pennit Fee O <br />Date Issued <br />Issuing Agent Signatu <br />11 Owner <br />Owner Given Reason for Denial <br />37-s <br />IX. Conditions of Approval/Reasons for Disapproval <br />nEC EIVE' <br />f% _ nn <br />Attach to complete plans for the system and submit to the County only on paper not less t Iff <br />8 1/9 11 V6,11n Jeu Z _L <br />BURNETT COUNTY <br />SBD -6398 (R0313) ZONING <br />