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ON COMPUTER/SCANNED <br />+.+aen to --p,rte uans mr cue system ana suomn to rue county only on paper not less than 8 1/2 x 11 in i ze MAY 1 ' 2017 <br />p <br />BURNETT COUNTY <br />SBD -6393 (R0313) ZONING <br />Industry Services Division�v <br />County, <br />vt� <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />' <br />P.O. Box 7162 <br />=, y <br />Madison, WI 53707-7162 <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 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 />3 y� <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />tioaos <br />e <br />P7 Sale- <br />` od yaoo <br />Property <br />Property Owner's Mailing Address <br />Property Location <br />W (� So .S f O �peA✓"f �G rt C <br />Govt. Lot 3 <br />y, y,, Section 1 <br />City, State <br />Zip Code <br />Phone Number <br />�t. FA.- l jyJ Al <br />5 - /d 7 <br />�ircle one) <br />T y0 N; R /.3 E or� <br />Il. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />®1 or 2 Family Dwelling — Number of Bedrooms <br />_ / <br />Block # <br />❑ Public/Cortunercial — Describe Use <br />❑ City of <br />❑ State Owned — Describe Use <br />❑ Village of 1 <br />X Town ✓Ae, lCSO rt <br />CSM Numb e % <br />I <br />1/r I�] <br />of <br />III. Type 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 />❑Pennit Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />11Pen-nitTransfer to New <br />List Previous Pennit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWYS System/Component/Device: (Check all that a I ) <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/Treat ent Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (sf) <br />DispersalArea Proposed (st) System <br />Elevation <br />6,00 <br />17 <br />9S7 <br />g6 4� <br />93 • o <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units � <br />o o <br />v <br />New Tanks Existing Tanks <br />E5 <br />^ <br />Septic or Holding Tank <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/MFRS Number <br />Business Phone Number <br />R/ CSC //11141H s <br />J�f>< <br />d.A-s 8.i/ <br />7/S�S�iG 'ci/S 7 <br />Plumber's Address (Street, City, State, Zip Code) <br />VIII. County/De artment Use Only <br />Approved <br />El Disapproved <br />Permit Fee <br />Date Issued <br />Issuing Ageft Si ature <br />�E] <br />$ 3,� <br />Owner Given Reason for Denial <br />IX. Conditions of Approval/Reasons for Disapproval n <br />�o &I?IG o,d �LaN� XeeIG <br />.s/,vovv o� <br />ECEPVE <br />ILG U <br />u <br />+.+aen to --p,rte uans mr cue system ana suomn to rue county only on paper not less than 8 1/2 x 11 in i ze MAY 1 ' 2017 <br />p <br />BURNETT COUNTY <br />SBD -6393 (R0313) ZONING <br />