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County �7 <br /> Industry Services Division �7�rnY7`!L <br /> t s 1400 E Washington Ave Sanitye umber(to be filled in by Co.) <br /> S P P.O. Box 7162 <br /> Madison,WI 53707-7162 <br /> 4etpt.,w�i <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this fonn to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary r-- <br /> u oses in accordance with the Privacy Law,s.15.04(l)(m),Stats. > <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel It <br /> 07-Oat y_a-39-lti-os-r- v d <br /> Cr f u ba/f Ooa -of/voo <br /> Property Owners Mailing Address Property Location <br /> YLI d N. m N s� Govt Loft <br /> City,State Zip Code Phone Number N(Al y, �y, Section <br /> d 3 I" /L3 7 (circle one) <br /> t^At✓fs+etwnt A2/V .S"6 (GSI- lyv8- els`G T N; R/eEorLV <br /> It.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms 1? Subdivision Name <br /> Blockft <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSNf Number ❑ Village of <br /> Town of I?&-,r k, <br /> ❑I.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' New System y- ❑ Replacement System ❑ TreatmenUHolding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 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) Design Soil Application Rate(gpdst) Dispersal Area Requited(st) Dispersal Area Proposed(so System Elevation <br /> YJ • .s 5 o a 17O0 9 3, a 4 9d. o <br /> VI.Tank Info Capacity in Forst #of Manufacturer v } <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks u n y u m <br /> o e, s <br /> c,V <br /> on tr; �15 ci. V C. <br /> Septic or Holding Tank `/ <br /> /OA a /DOd / W/x�J c✓ ( <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) ,/ <br /> !� 0 fc�w! -: .S lij/� �Yr 7Nr1- S/y <br /> 6f,-T <br /> VIII.County/Department Use Only <br /> Permit Fee Dale Issued Issuing A n[Si <br /> / store <br /> Approved ❑ Disapproved $ / <br /> 11Ol —/� <br /> Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D ECI"Em9VE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8112 x 11 in sin Ze All U 6 <br /> 2016 <br /> SBD-6398 (R0313) BURNETT COUNTY <br /> ZONING <br />