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County <br /> rrr T Industry Services Division l3JA- <br /> ✓rivp+ <br /> ! pS „ �(r'; 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 �! ' <br /> S Madison,WI 53707-7162 <br /> Sanitary Permit Application State TransactionNxniSr —/I <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,subnussion of this Corm to the appropriate governmental unit �l a 1 <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 addres ) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary /- .7a <br /> pro & <br /> poses in accordance with the Privacy Law,s.15.04(1)(m),Stats. y z <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel a G ly _/` J,7 <br /> ,ria&A M, ?h ;l�: J ro -3r3--od5ooa <br /> Property Owner's Mailing Address Property Location <br /> 13 da Jt"- /vF Govt.Lot <br /> City,State Zip Code Phone Number y,, ''%, Section 7 7 <br /> 156A Z ,c y (circle one) <br /> II.Type of Building(check all that apply) Lot# T e149 N; R 16 E oaP <br /> I or 2 Family Dwelling -Number of Bedrooms d Subdivision Name <br /> Block# jeaD1 . )Is <br /> Public/Commercial-Describe Use % k 6k--J10re-1 <br /> / <br /> ( ❑ City of <br /> ❑ State Owned-Describe Use CSM Number ❑ Village of <br /> Town of 04 klA M 4e <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System Replacement System ❑ 'I'reatmenUHolding Tank Replacement Only ❑ 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 /> IV.Type of POWTS S stem/Com onent/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) Design Soil Application Rate(gpdst) Dispersal Area Required(s0 Dispersal Area Proposed(st) System Elevation <br /> YSv <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Fxisting Tanks v =' 6 <br /> c U vi v; ii V CL <br /> Septic or Holding Tank �6G a ♦OdQ <br /> Dosing Chamber !OQ l6Bd <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu-m�ber's�Signature MP/MFRS Number Rosiness Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7'7(oO 3f 1/0Jr?er r-3 <br /> VIII.Coun /De artmen Use Only <br /> Approved ❑ Disapproved Perrin Pee D p `Date Issued Issuing Agent Sign r <br /> El Owner Given Reason for Denial $ `-'lee / ! ` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> CEI S <br /> Attach to complete plans for the system and submit to the County only on paper not less than A 1/3 x 11 in ttLijilize <br /> SBD-6398 (R0313) JUL 2 U 2016 <br /> BURNETT COUNTY <br /> 7nuflur <br />