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Attach to complete plans for the system and Sillitatt to me courtly only on paper no[ im man a uz X1 U 3," SEP 0 7 2018 U <br />7 <br />SBD-6398 (R. 11/11) BURNETT COUNTY <br />ZONING <br />V <br />Safety and Buildings Division <br />'y <br />S <br />201 W. Washington Ave., P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />Madison, WI 53707-7162 <br />'S c�r <br />Sanitary Permit Application <br />State Transaction Number <br />'4114— <br />In accordance with SPS 383.21(2). Wis. Adm. Code, submission of this farm to the appropriate governmental unit <br />Pmject Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned PONVTS are submitted to <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). Slats. <br />/CV. <br />I. A plication Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />Wq I/V &I.,70ri <br />Property Owner's Mailing Address <br />-- <br />Property Location <br />Z Ivi-m, se cr,6 <br />GovL Lot 14 <br />Section .44- <br />CiL)1A-tare <br />Zip Code <br />PhoneNumber1/�, <br />&&A', olif <br />JOCIQ <br />T N; R le on <br />11. Type of Building (check all that apply) <br />Lot 1, <br />Subdivision Name <br />�1 or 2 Family Dwelling -Number of Bedrooms <br />Block <br />0 Public/Commercial - Describe Use <br />0 city Of <br />0 State Owned - Describe Use <br />Cl Village Of <br />OrTown of V�j 0 k -l& -j <br />CSM Number <br />V Z /get <br />111. Type of Permit- (Check only one box on line A. Complete line B if applicable) <br />A. <br />0 New System <br />Replacement System <br />Treatment/Holding Tank- Replacement Only <br />0 Other Modification to Existing System (explain) <br />❑11 <br />B. <br />0 Permit Renewal <br />Permit Revision <br />0 Change of Plumber <br />0 Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before ExpirationI <br />Owner <br />IV. Type of PON41TS Systeni/ComponentfDevice: (Check all that apply) <br />$:Non -Pressurized In -Ground 11 Pressurized In -Ground C1 At -Grade 11 Mound > 24 in. ofsuitable soil El Mound < 24 in. of suitable soil <br />11 Holding Tank 0 Other Dispersal Component (explain)_❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Dispersal Area Proposcd(sf) <br />Design Flow (gpd) Design Soil Application Ratc(--pdsf) Dispersal P -a Required (sf)System Elevation <br />30c) y q;7 <br />a Capacity in Total r of Manufacturer <br />V1. T nk Info <br />Gallons Gallons Units d <br />tilew Tank; Fvdsting Tanks o g 5 <br />V; rn <br />Septic or Holding Tank <br />=/Zcv <br />I <br />c 0 <br />X <br />Dosing Chamber <br />---7�O <br />x <br />VIT. Responsibility Statement- L the undersigned, assume responsibility for installation of the PONIFTS shown on the attached plans. <br />Plum 'sName (Print) <br />Plumber's Sioturc, <br />MPiMPRS Number <br />Business Phone Number <br />59 <br />Plumber's Address (Street, City, State, Zip Code) <br />?-7296 'J" 54,9u, <br />VIII. County/Department Use Only /,*7 <br />Approved <br />0 Disapproved <br />1 <br />Permit FCC <br />S p0 <br />Date Issued <br />Issuing Agent Signature <br />0 Owner Given Reason for Denial <br />2 <br />IX- Conditions of Approval/Reasons for Disapproval <br />.V1-111/ <br />,APPROVED E 041 E � V E <br />Attach to complete plans for the system and Sillitatt to me courtly only on paper no[ im man a uz X1 U 3," SEP 0 7 2018 U <br />7 <br />SBD-6398 (R. 11/11) BURNETT COUNTY <br />ZONING <br />V <br />