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.yt—...n cu PMW P— run We sysrem nes swe®t TO rhe a,onnty Otey o® paper not less than 5: pi—in <br />mile M=N u V Ulna <br />AUG 29.2018 <br />SBD -6398 (R. 08/14) <br />BURNETT COUNTY <br />ZONING <br />Industry Services Division <br />1400 E Washington AvejLfp. <br />County <br />P.O. Box 7162 <br />Sanitary permit Number (to be filled in by Co.) <br />Madison, WI 53707-7162 <br />e <br />Stn.n <br />Sanitary Permit Applieati®n <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 />-7C' <br />_purposesin accordance with the Privacy Law, s. 15.04(1_Km), Stats. <br />q ,z- S, 1-�7��/ / /. <br />I. A lication Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />bA-V11) D ' CyN-T-,HIA /- AAjc)erzs <br />0.7-6'1�-Z-39-ib-32,T=5 dS_OCz,I <br />Property Owner's Mailing Address <br />property Location <br />_ 5 Z_ 7AY AR b -A V �- <br />�/ <br />Govt. Lot 3 f T <br />IV V� /4, Si; %4, Section s <br />City, State <br />Zip Code <br />Phone Number <br />5T 0�1 UL <br />SS/ / <br />circle one <br />T N; R I & E o W <br />IL Type of Building (check all that apply) <br />Lot # <br />or 2 Family Dwelling - Number of Bedrooms <br />— <br />Subdivision Name <br />.NA <br />Block # <br />❑ Public/Commercial - Describe Use <br />-- - <br />❑ <br />City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />IS Town of A4 F=Ew <br />III. <br />Type of Permit: (Cheek only one boa on line A. Complete line B if applicable) <br />A. <br />XNew System ys <br />C1 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 Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS S stem/Com nent/Device: Check all that apply) <br />❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grain ❑ 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 rsal/Treatttleat Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />So <br />� <br />Na- <br />��_fklf <br />VI. Task Info Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Ciallons <br />Units <br />o a <br />i Nes Tanks Existing Tanks <br />o <br />in y rn is. i• <br />0. U CzJ <br />Sol— Hot&%Task ? fi CQ—I <br />Z, c GLS <br />D-s4ig-Ow- <br />VII. Responsibility Statement- I, the andersigned. ass readpsibility for installation of the POWTS shown on the attached platy. <br />Plumber's Name (Print) <br />Plumbo/s Sign a <br />MP1i0li31" Number <br />Business Phare Number <br />CfW-ZV - 5 /V <br /><a/1y <br />-7i,�9- 4b- F-90 <br />Plumber's Address (Street, City, State, Zip Code) <br />?50& 6t&K twoK Rb. <br />VIII. Count /Department Use Only <br />Approved <br />❑ DisapprovedPermit <br />Feee� <br />Date Issued <br />Iss ing Agent Signature <br />❑ Owner Given Reasfor <br />on Denial <br />$TJ <br />I Q <br />V I v <br />IX. Conditions of Approval/Reasons for Disapproval l <br />'J C, To, �� I,nS���-`�or'S' �S�etS 5�✓>G� �p �a ��a� �aS <br />.yt—...n cu PMW P— run We sysrem nes swe®t TO rhe a,onnty Otey o® paper not less than 5: pi—in <br />mile M=N u V Ulna <br />AUG 29.2018 <br />SBD -6398 (R. 08/14) <br />BURNETT COUNTY <br />ZONING <br />