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Industry Services Division <br />4$ <br />County <br />- <br />Sanit P rmit umber to be filled in by Co.) <br />ZM081 <br />7. <br />" � 1400 E Washington Ave <br />ON COM UTEPJ x 7162 <br />53707-7162 <br />�`ssirnso �t <br />i <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 />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 Services. Personal information you provide may be used for secondary <br />3S0 <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />a7 <br />I. Application Information — Please Print All Information <br />A M7 ;So W <br />Proper70w is Name <br />Parcel # <br />Property Owner's Mailing Address <br />Property Location <br />2S 7 42 <br />Govt. Lot y <br />'/4, Y<, Section 3� <br />City, Stat <br />Zip Code <br />Phone Number <br />AIQ <br />(circle o <br />T-1DN R/4 Eo AD <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />II I or 2 Family Dwelling — Number of Bedrooms <br />Block # <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />❑ State Owned — Describe Use <br />El Village of <br />CSM Number <br />Town of <br />III. Type <br />of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />® New 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 <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />Owner <br />IV. <br />Type of POWTS System/Component/Device: (Check all that apply) <br />❑ 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 />Design Flow (gpd) <br />Design Soil Application <br />Dispersal Area Required (so <br />Dispersal Area Proposed (sf) <br />System Elevation <br />Rate(gpdsf) <br />VI. Tank Info <br />Capacity in <br />d <br />Gallons <br />Total # of Manufacturer b <br />Gallons Units 2 0 <br />U <br />2 2 <br />U <br />New Tanks Existing Tanks <br />a U <br />i7n y <br />cn w U <br />G. <br />Septic or Holding Tank <br />® <br />❑ <br />❑ ❑ <br />❑ <br />Dosing Chamber <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />VII. Responsibility Statement- I, the undersigned, assume responsi ' ity for installation of the POWTS shown on the attached plans. <br />Plumb r' amV(P nt) <br />Plumber' SiV�� <br />MP/MPRS Number <br />Business Phone Number <br />IZ <br />L <br />/ ,! �— <br />Plumber's Address (Street, City, State, Zip Code) <br />VIII. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />0 <br />Date Issued <br />Issuing Agent Signature <br />El Owner Given Reason for Denial <br />� <br />$ 3 7--- , <br />AO " a ' 7 <br />IX. Conditions of Approval/Reasons for Disapproval <br />or �i,��cr�, n <br />OCT 0 2 <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x MinchUin size 1 �/ <br />13URNETT COUNTY <br />SBD -6398 (R03/14) <br />ZONING <br />