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a <br />` ": <br />Industry Services Division <br />County <br />i3� r f/ RX 67ea0 <br />�.�; <br />S <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />t �k <br />P.O. Box 7162 <br />Madison, N/I 53707-7162 <br />S;ft N- _Do <br />� <br />. y,.o <br />� o -n iD <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 />'v —# <br />is required prior to obtaining a sanitary pennit. 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 information you provide may be used for secondary <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />t <br />I. Application Print <br />Information — Please All Information <br />Property Owner's Name <br />Parcel # <br />lCur, / /9u <br />Dr -Doi- o�l000v <br />Property Owner's Mailing Address <br />Property Location <br />_"7Z/0 G✓a�g%i %ct1 vt /�%v ° S. <br />Govt. Lot IF' <br />%, %, Section /3 <br />City, State <br />Zip Code <br />Phone Number <br />lS i✓i,v,,,. s-j--zl <br />0 <br />6 /d' 9 9/, 3 e g o <br />(circle one <br />T yo N; R /_5— Eor4 <br />CI. Type of Building (check all that apply) <br />Lot # <br />❑ 1 or 2 Family Dwelling — Number of Bedrooms <br />3 <br />Subdivision Name <br />Block # <br />❑ Public/Cornmercial — Describe Use <br />❑ City of <br />El State Owned —Describe Use <br />❑ Village of <br />CSM Number <br />Z Town of `l 4 G /C 5& yr <br />Iii. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A' <br />❑ New System y <br />11 Replacement System <br />❑ Treatrnent/Holding Tank Replacement Only <br />®dd Other Modification to Existing System (explain) <br />/kNCi+ YJ 0. t w '441 <br />B <br />❑ Permit Renewal <br />❑Permit Revision <br />ElChange of Plumber <br />❑Permit Transfer to New <br />List Previous Permit Number and DatBefore %/e <br />Expiration <br />Owner <br />GN 1p717 <br />7 _7 <br />IV. 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. Dis ersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />300 <br />yid. <br />Vi. Tank Info <br />Capacity in <br />Total # of <br />Manufacturer <br />Gallons <br />Gallons Units <br />v <br />; o <br />v <br />New Tanks <br />Existing Tanks° <br />5 v <br />Y <br />a y H <br />w U a <br />Septic or Holding Tank <br />/ <br />Dosing Chamber <br />VII. Responsibility Statement- 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 />k o e k_, <br />�2 - ,f/ <br />�d -9's-1 <br />'7 �6 -ylr7 <br />Plumber's Address (Street, City, State, Zip Code) <br />0 17 w 1 3S �t✓ I/v �� may, <br />VIII. County/De artment Use Only <br />Approved <br />El Disapproved <br />Per�mfit Fee <br />Date Issued <br />Issuing Agent Signatur <br />❑ <br />�v ' <br />y� a <br />Owner Given Reason for Denial <br />/ <br />7 - <br />Ix. <br />CX. Conditions of Approval/Reasons f� Disapproval � � /JCvM� , <br />iiid /-ac� �te te, �c✓N�f 922 o 1,/s A �N, /' ,Ny D9 V EA <br />l4ewee, <br />MAR 2 6 2018 <br />SBD -6398 (R0313) <br />+«� „ to —III ULe plans for the system nos uoma to me county only on paper not less than 8 1/2 x I l'fnche+-& size LJ <br />BURNETT COUNTY <br />ZONING <br />