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- kR !� ti � <br />,�' <br />Industry Services Division <br />1400 E Washington Ave <br />� Y <br />umber (to be fiikd in by Co.} <br />Sanitary Permit Nlp <br />6 0a 3 <br />r ■ a <br />' <br />P.O. Box 7162 <br />Madison, W153707-7162 <br />K <br />Ll <br />Sanitary Permit Application <br />Stare Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />JVA <br />_ <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 Services. Personal information you provide may be used for secondary1 <br />purposes in accordance with the Privac Laws. I5. 1 m Stats. <br />µ �\) <br />I. Application Information - Phwe Print AN Information <br />Property Owner's Name <br />Pared <br />DAVID tf , € Y AT H L" OX W E ,� <br />Property Owner's Mailing Address <br />Property Lavation <br />X603 'KC)yQ" LAK- RcA <br />— <br />cavr.I.ot ti1>� <br />5 ,%, Section 15 <br />�- <br />City, State <br />Zip Code <br />Phone Number <br />5 PODA) erg VXT <br />5 8 a ! <br />-- <br />(circle one <br />T N; RJ_EorE) <br />II. Type of Building (t�reck all tlet apply) <br />Lot # <br />X1 or 2 Family Dwelling - Number of Bedrooms --" <br />Subdivision Nam <br />Block # <br />0 Public/Commercial - Describe Use <br />-" <br />❑City of <br />0 State Owned- Describe Use <br />0 Village of <br />CSM Number <br />ATown <br />III. <br />Type of Permit: (Cbmk only one box on line A. Complete line B if applicable) <br />A. <br />0 New System R e3slaoetrternt System <br />❑ Trenrrnemt/Holding Tarek Replacement Only--± <br />nly <br />0 Other Modification to Existing System (explain) <br />B• <br />❑Permit Renewal ❑Permit Revision <br />❑ Ctnarnge of Plumber <br />©Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. T of POWTS S o tMcvice: (Cbeck all ties# <br />Non-lrresui iced <br />h.Gro red 0 Pnesstmited In -Ground ❑ At -Grade 0 Morand ? 24 in. of sink soil 0 Mound < 24 m. of sujW4e soil <br />© Holding Tank 0 Other Dispersal Component (explain) 0 Prat Device (explain} <br />V. ' rsaltTreatmentAreaInformation: <br />Design Flow (gpd) Design Soil Application Rabc(gpdsf) Dispersal Amer Required (st) Dispersal Area Praposod ( SYS Elevation <br />0,7 <br />4,gz, (0 lea �9 Po q7.�o q6 6 <br />VI. Task Info Capacity in Tota! # <br />of Manufacturer <br />Gallons Units t <br />New Tanks Existing T�kg' Z j +� <br />U yr on rn ts. C7 Ar <br />Septic �� 00 r��5 <br />VII Regloftibility Stateameeet- I, tie o _ <br />Plumber's Name Prirrt a i for hrsWbrtion of the POWTS sinner on tie attached t�� <br />eOgy.� �t�n e / s Busitteas Phone Number <br />/ `e`rCiv3� <br />Plumber's Address (srrea City, State Zip Cade) I� <br />VIII. Conn rtment Ust Only <br />ed ❑Disapproved Permit Fee �bsued ng Agennt Si© <br />' 3 7 5 <br />Owner Givesn Reason for Denial 5- 0 12 <br />IX. Conditions of Approval/R*meas far I}isapprtwai <br />Gon�:�St'nOf" 6j1� C II 3 �nv51+ 6e__ <br />r 0� S�Or -1 ` <br />1 <br />NPRUE <br />n <br />Aegeh to pros for the sYatem jai sept to the Caeety only o. pa'er eat hyo t§w tr t/Y : s <br />NOV 7 2017 <br />U) <br />51317-6398 (R 08/14) <br />BURNETT COUNTY <br />ZONING <br />