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Attach to complete plans tot the system and suhml[ to the County only on paper not less man a w. x t t mcnes «'-' "— <br />DEC 12017 <br />SBD -6398 (R. 11111) <br />BURNETT COUNTY <br />Zoo-41NG <br />County <br />45>, ,� <br />Safety and Buildings Division <br />err <br />0`2W <br />j ® ` <br />201 W. Washington Ave., P.O. BOX 7162 <br />Sanitary Permit (ttoo}be filled in by Co.) <br />p�� <br />Madison, WI 53707-7162 <br />tNNu/mbeer <br />4• <br />7 <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 />purposes in accordance with the PrivacyLaw, s. 15.04(1)(m), Stats. <br />--6+0 r <br />W h <br />I. Application Information - Please Print All Information <br />e L <br />Property Owner's Name <br />Parcel # <br />6-7 ��/y-�j- S 0-5 <br />i�J� r' R �� J ►� <br />Proper``ty Owner's Mailing Address <br />Property Location <br />� p i� /� C� [� <br />11 Z VV VV e Li 6 W "� �"'" N� <br />Govt. Lot 5__ Q <br />/ V,, Section - 1 <br />City, State <br />Zip Code <br />Phone Number <br />( <br />5 q � <br />`� (circle one <br />T N; R E orb <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />❑ 1 or 2 Family Dwelling - Number of Bedrooms <br />&A f'k�<, l2(J POP <br />Block # <br />$Public/CommeTeial - Describe Use <br />❑ City of <br />El State Owned -Describe Use <br />El Village of <br />WEE t� I- <br />,Town of 1.7 <br />CSM Number <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A <br />ew System <br />❑ Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B• <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS System/Component/Device: Check all that apply) <br />ANon-Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: GUM( 1- °'"'rl 15E R-5 <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (sf) System <br />Elevation <br />.375 <br />J <br />1R9z.65 <br />2V0 <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />0 <br />Gallons <br />Gallons <br />Units <br />2 <br />New Tanks Existing Tanks <br />Septic or Holding Tank <br />Dosing Chamber <br />ji6ow4k attached plans. <br />VII. Responsibility Statement- I, the undersigned, assume responsibility foy installation of the POWTS shov <br />Plumber's Name (Print) Plumber's Sitore <br />RSI er <br />Business Phone Number <br />_._l c, FF- <br />Plumber's Address (Street, City, State, Zip Code) <br />VIII. Coun /De artment Use Only <br />JApproved <br />D Disapproved <br />Permit Fee <br />$ 3 75� <br />Date Issued <br />Issuing Agent Signature <br />❑Owner Given Reason for Denial <br />/ ak <br />IX. Conditions of/ Approval/Reasons for Disapproval <br />Cd���luT/DNS �y''� i'U✓- 31 �1Je�v G2�n/Js,�Ps . <br />r= rNk <br />lu-2 <br />Attach to complete plans tot the system and suhml[ to the County only on paper not less man a w. x t t mcnes «'-' "— <br />DEC 12017 <br />SBD -6398 (R. 11111) <br />BURNETT COUNTY <br />Zoo-41NG <br />