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��RTyt_i'dust <br />Industryi SCb}Qn� <br />ashinn mPUTE <br />Coon <br />^,Ie( <br />' <br />/ <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />Permit _N//w,^nber (to be filled in by Co.) <br />S� <br />Sanitary Permit Application <br />State Transaction Number <br />A[,* <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmerutal unit <br />" <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 />purposes in accordance with the Priv Law s. 15.04(1&Stats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />DAV117 � IM WE 74USDE-M0RE <br />07- 017-- Z-yQ-/s-�s �" 05-_ao6' <br />Property Owner's Mailing Address <br />Property Location 0/ 060 <br />Govt- Lot <br />Section 35- <br />City, state <br />Zip Code <br />Phone Number <br />n <br />C- SENT I <br />y <br />�i <br />IL Type of Baring (check all that apply) <br />Lot # <br />'9.1 or 2 Family Dwelling - Number of Bedrooms 3 <br />Subdivision Name <br />Block # <br />❑ Public/Commercial - Descn'be Use <br />_ <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />Town of _TA (21< -5 64 <br />III. Type of Permit- (Check only one box on line A_ Complete lice 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 />❑ 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 />SYBS �— S- 117 <br />IV. Type of POWTS S Co nVI)evice: Check all that <br />on Pressmriad to Gronmd ❑ Ptess wind tr-Grorrnd ❑ 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 reatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rae(gpdsE) <br />Dispersal Am Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallas <br />Gallons Units o <br />y <br />New Tmrks Exiting Tanks <br />o V <br />m <br />Ot Q <br />000 EsEK iC <br />VII. Responsibility Statement- I, the ande 'lity for insolation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) umber Business Phone Number <br />�'v,�y S>4 c Ks©nl s 4335' 7i5 �q qq <br />- b_ <br />Plumber's Address (Street, City, State, Zip Code) <br />013N.0 P3tAC 13/1,009 MOAQ lnlEBsr-e,,� vi-� . S7 <br />VIII. Conn rtment Use Only �z <br />Approved <br />❑ Disapproved <br />Permit Fee ° D <br />s <br />Date Issued <br />Lssuing Agent Si <br />11 Owner Givers Reason for Denial <br />37'S• <br />le 30 - �7 <br />IX. Conditions of Approval/Reasons for Disapproval <br />/ �/J t/ <br />�ySTe/N �LE ua 7• o.vS a rle G'f� t;�a L, /'/ v5" Av 0 v e ✓' D ile r CgZLL , <br />U V r� <br />SBD -6398 (R. 08/14) OCT 31 1117 <br />UD <br />BURNETT COUNTY <br />ZONING <br />