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Attach to complete pions for the sys em and submit to the County only on paper not less than 8 trz x i l inc in e <br />BURNETT COUNTY <br />SBD -6398 (R031 1) ZONING <br />Industry Services Division <br />County <br />[?4 r 0 <br />'•+ <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />;' <br />P.O. Box 7162 <br />Madison, WI 53707-7162fl <br />Sanitary Permit Application <br />State Transaction Number <br />4114 <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br />SOD 8� <br />purposes in accordance with the Privacy Law, s. 15.04(t)(m), Stats. <br />Or. <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />d 7, -5- <br />roperty Owner's Mailing ALddress <br />Property <br />Property Location <br />l W . L A /iG S7` <br />Govt. Lot <br />y,, y,, Section <br />City, State <br />Zip Code <br />Phone Number <br />M N <br />`��/ 6circle <br />_ <br />one) <br />T N; R / E o�r <br />Lot # <br />II. Type of Building (check all that apply) <br />S,ub�division Name <br />Sri or 2 Family Dwelling — Number of Bedrooms <br />4 <br />// �PSfO✓i <br />/�/�i✓�✓Qt!/Q!l a� <br />Block# <br />4o+ 35 <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />11 State Owned —Describe Use <br />❑ Village of <br />CSM Number <br />0 Town of :nw i s S <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 />❑ 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 />+�'� 0 (� 2, — 0.) —q11 <br />IV. Type of POWTS System/Component/Device: (Check all that apply) <br />RNon Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil <br />❑ Mound < 24 in. of suitable soil <br />El Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design FIow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) System <br />Elevation <br />us C) <br />• 77 <br />1 & v-? <br />I 6q <br />73- `7 <br />VI. Tank Info <br />Capacity in Total # of Manufacturer <br />Gallons Gallons Units <br />U <br />N <br />New Tanks Existing Tanks <br />a <br />U cn h <br />:n <br />ti U <br />a <br />Septic or Holding Tank <br />'16 <br />Dosing Chamber <br />V11. 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 />NIP/MPRS Number <br />Business Phone Number <br />Plumber's Address (Street, City, State, Zip Code) <br />7760.., t�.� �.� �; syr? <br />. ,R� <br />VIII. County/De artment se Onl <br />Permit Fee Date Issued Issuing Agent Signa re <br />Approved El Disapproved v0 <br />$ _ <br />❑ Owner Given Reason for Denial <br />IX. Conditions of Approval/Reasons for Disapproval <br />' <br />ATP <br />E C E M E <br />lI t <br />Attach to complete pions for the sys em and submit to the County only on paper not less than 8 trz x i l inc in e <br />BURNETT COUNTY <br />SBD -6398 (R031 1) ZONING <br />