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nuauu io cu-piete puns mr the system and submit to [ne county only on paper not less than 8 1/2 x 1 I i hes Tze APR' f " <br />1 D 2017 U <br />SBD -6398 (R0313) BURNETT COUNTY <br />ZONING <br />Industry Services Division <br />Coun <br />r h ,e' <br />.s psi <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Sanitary Permit Number (to be tilled in by Co.) <br />j <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />the Department of Safety and Professional Servies. Personal infonnation you provide may be used for secondary <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />?rr <br />Parcel # <br />o-2- odO -d- 4v-r� �od-sc,S <br />5 c � <br />04 odo <br />Property Owner's Mail' <br />g�Adddress <br />Property Location <br />IOSI� <br />/ / ,z <br />Govt. Lot &3 <br />y, y,, Section <br />City, State <br />Zip Code <br />Phone Number <br />-T �.Vf <br />030 <br />_? <br />(circle o&T �L.tL N. R _�� E o ,1 <br />II. Type of BAding <br />check all that apply) <br />Lot # <br />Subdivision Name <br />1 or 2 Family Dwell' <br />g - Number of Bedrooms <br />a el <br />Block # <br />❑ Public/Commercial - <br />Describe Use <br />❑ City of <br />❑ State Owned-Describe <br />Use <br />❑ Village of <br />CSM Number <br />Town of 1A N /i <br />IW <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />El New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />Other Modification to Existing System (explain) <br />B. <br />El Permit Renew I <br />❑Permit Revision <br />❑Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiratio <br />Owner <br />IV. Type of POWTS S stem/Com onent/Device: (Check all that apply) <br />Non-Pressurized In-d ound ❑ 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 ApplicationRate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (st) <br />System Elevation <br />e o I <br />yAll <br />yyd <br />VI. Tank Info <br />Capacity in Total # of Manufacturer <br />I Gallons Gallons Units <br />o a <br />" <br />o <br />New Tanks Existing Tanks <br />v <br />2 <br />m <br />r U in rn <br />w V <br />a <br />Septic or Holding Tank <br />�O O I <br />Dosing Chamber <br />VII. Responsibility <br />S atement- 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 />/2re-/G 141A <br />G <br />Plumber's Address (Strect, <br />City, State, Zip Code) <br />of 7 76 O <br />.... y 3Y- <br />III. County epartinent Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee D <br />$ <br />Date Is/sued <br />Issuing Agent Signa tre <br />/�_� <br />❑ O <br />i er Given Reason for Denial <br />37S." <br />�' / D " <br />IX. Conditions of Approval/Reasons <br />for Disapproval <br />D ECEW� <br />nuauu io cu-piete puns mr the system and submit to [ne county only on paper not less than 8 1/2 x 1 I i hes Tze APR' f " <br />1 D 2017 U <br />SBD -6398 (R0313) BURNETT COUNTY <br />ZONING <br />