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mus <br />. :,.. ON COMP <br />s� y �- <br />�. <br />NEDirvilwAve- P -a am.. �� <br />Madism W 537th -7-r-.. <br />Sanitary Permit Application <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate goverr as <br />r <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned PO\M1TS are stAwniae <br />the Department of Safety and Professional Servies. Personal information you provide may be used for secoadar% m <br />purposes in accordance with the Privacy Lav: s. 15 04 (1) (m), Stats. �% (f � �� r� t �� � _ a} <br />T Annitrstintl Tnfnr.n�trnn _ P6—. D.vot Ait T -f ..matin.. f/` 6 F! [ ZN/1 <br />Property Owner's NameParent <br />9 ijJ�7 <br />— os­oQ�J IIl�i L1tlr./. <br />Property Ocaner s Mad301 ing, ress <br />Propem Locstiaer _ t <br />t t <br />Govt. Lot <br />b. I <br />Citv,,Statq <br />I <br />Zip Code <br />Phone Number <br />G✓�^ <br />I <br />k <br />T 'T N: R ys+ J <br />II. a of Building (c k all that apply) <br />Lot � <br />t or 2 Family Dwelling - Number of Bedrooms <br />_ <br />Subdivision Name <br />❑ Pubbc/Commerclal - Describe Use <br />Block I <br />Cit) of <br />❑state Owned -Describe Use — <br />--TotvTt <br />L V ll <br />ia ts'e of <br />CSM Num <br />Number <br />of _ <br />III. <br />Type of Permit: (Check only one box online A. Complete line B if applicable) <br />A. <br />❑ New System <br />❑ Replacement System <br />xTreatmentlHoiding Tank Repiarer?wnt Onl% <br />:' t thea Modification to Existing System (ex <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />Change of PlumberPernt*t Trans er to Nei <br />i <br />Ltu Previous Permit Number and Date Issued <br />Before F.xpiratinn <br />F <br />J\,.UCLA an uiat i 7f ) <br />❑ Non -Pressurized In -Ground 7 Pressurized In -Ground J At -Grade L Llou nd > 24 in. of suitable soil 0 Mound < 24 in, of suitable soil <br />Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis rsalfrreatment Area Information: <br />Design Flow (gpd) Design Soil Application Rate(gpdsi) Dispersal Area Required (st) Dispersal Arca Proposed (sfl Sy em Elevation <br />v <br />VI. Tank Info Capacity in Total it of Manufacturer <br />Gallons Gallons Units E <br />New Tanks Existing Tanks <br />a U tr m 47 <br />Septic or Holding TankO t) ` ,t t <br />Dosing Cltamher - 1�/ i <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attachedplans. <br />Plumber's Name (Print) Plumber's Signature \4P,'%IPRS Number Business Phone Number— <br />A./ <br />umb rA/ K h�.,� $a.►.1 1 OR 5 713 /o f %o® <br />Plumber's Address (Street, City, State. Zip Code) <br />1-70 07or'ti ---k L4_) rod( <br />VIIL County/Department Use Only <br />Approved ❑ Disapproved Perntit Fee Date Is ted Issuing Agen St g Wore <br />1,7 <br />El Owner Given Reason for Denial <br />> Conditions o� ApprovaURe � � v �a�Q vol <br />t� . 6 I <br />R ,secs 40 Mr-%ZA or- 1q_1x/1_C.eA1 9 �rD <br />M v s� Me c,T .50 ,1 Cove_,,-- �� dt 5 � c�1 �v �� ems'' D WE <br />E C_"' E <br />Attach to complete plans for the system and submit tot County only on paper not less than 8 t2 x 11 inches in sir JUN 2 3 2017 <br />%D -mea (R. I I,1I) BURNETT COUNTY <br />ZONING <br />