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Attach to complete plans for the system and submit to tae county omr on paper not rest 911211 o rrc r U u 211'c r 09 <br />2017 [Ljj BURNETT COUNTY <br />SBD -5398 (R. 11/11) ZONING <br />Safety and Buildings D'�vision <br />-Coardy luwd�— <br />Sanitary Permit Numb be be filled in by Co.) <br />D _:: <br />S <br />201 W. Washington Ave.. P.O. Box 7162 <br />pS -f <br />Madison, Wt 53707-7162 <br />1 <br />, <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.2] (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 />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />7 /�,�J (r <br />q/7 J / �� <br />1. Application Information - Please Print All Information <br />Property Owner'�sp`a/me <br />Parcel# <br />Property Owner's Mailing Address <br />Property Location <br />Govt. Lot, <br />y,, % Section <br />City, State <br />Zip Code <br />Phone Number <br />err � <br />15170 <br />etreleo <br />T�N; R�E� <br />U. Type of Building (check all that apply) <br />Z <br />Lot # <br />Subdivision Name <br />tg 1 or 2 Family Dwelling - Number of Bedrooms <br />lock❑Block- <br />0Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of L' - <br />"Town <br />CSIVI Number <br />:#m V.1. n O <br />of <br />III. Type of Permit: (Check only one box. on line A. Complete line B if applicable) <br />A. ❑ New System <br />❑ Replacement System <br />JrTreatmentl;irii"S Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. ❑ Permit Reneuml <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to Nevt <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS S stem/Cora nent/Device: (Check all that apply) <br />P[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 />nformation:Design <br />DesignFlow (=pd) <br />Design Soil Application Ratc(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sl) <br />System Elevation <br />(i�(J\ <br />'7fl <br />VI. Tank Info <br />Capacity in <br />Total <br />t of Manufactim <br />, <br />Gallons <br />Gallons <br />Units <br />u a a <br />a U A u, <br />o a <br />m t. O G <br />New Tanks Existing Tanks <br />Septic or Holding Tank <br />0 <br />7i; D <br />Gp <br />Dosing Chamber <br />/ 6 <br />666 <br />4 911f 4-j <br />VII. Responsibility Statement- L the undersigned, assume responsibility for Installation of the POWTS shown on the attached plass. <br />Plum is Name (Print) <br />Plumber' ignaturc <br />%o <br />MPWRS Number <br />�y'S7`�S <br />Business Phone Number <br />?i5' �Gf -oZoZ <br />Plumber's Address (Street, City, State, Zip Code)_ J n l <br />-TQP"i--x3/1f Ac W�35ff Q', L'Jt 5-'1n <br />VIII. County/Department Use Only <br />Approved ❑ Disapproved Permit Fee Date Issued issuing Agent Si <br />X5 00 <br />A7 <br />❑ Owner Given Reason for Denial 3 711 • — �� / <br />i'X. CtLonditioZf ApprovallfReasons for Disapproval / 1 14� / <br />��/�Lat�i.,t/N/� G�• <br />ST�P� rrr�4ajAn!der/Iwxl <br />n <br />En.f T NJl "at GL !� POd `,, e.V1 �iGi`er /`1GSe D ECEOV <br />Attach to complete plans for the system and submit to tae county omr on paper not rest 911211 o rrc r U u 211'c r 09 <br />2017 [Ljj BURNETT COUNTY <br />SBD -5398 (R. 11/11) ZONING <br />