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Attach to complete plans for the system and submit to the Count• onlg on paper not less than O t chez in srze <br />AUG 13 2018 <br />SBD -6393 (R. 11/11) IU <br />BURNETT COUNTY <br />7t7NIN(. <br />ty <br />�/(V <br />:. <br />Safety and Buildings Division <br />(AJ <br />201 W. Washington Ave., P.O. BOX 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />Madison, Wl 53707-7162 <br />6LA 3a-1 <br />Sanitary Peiinit Application <br />State Transaction Number <br />� —_ <br />A/W <br />In accordance with SPS 383 21(2), Vis. 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 orSafety and Professional Servies. Personal information you provide may be used for secondary <br />purposes in accordance with the Privacy Law, s. 15.04(l)(m). Stats. <br />I. Application Information — Please Print All Information <br />Property Owner`s Name <br />Parcel R <br />",rd <br />Property Owner's \tailing Address <br />LN <br />Property Location <br />ZCityp <br />5 MMU 1,VJ <br />Govt. Lot -I- <br />y/Section ICA <br />IE <br />City, <br />, State <br />� <br />Zip Code Phone <br />Number <br />ly W%t <br />5y1330 7.5^6 <br />Z <br />T �' N; R � J E oW <br />Ii. Type of Building (check all that apply) �j Lot <br />r <br />Subdivision Name <br />YI or 2 Family Dwelling —;`lumber of Bedrooms / <br />Btock= <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />❑ State Owned — Describe Use CSNI <br />❑ Village of <br />Number <br />R'Towm of ? UV J J 5 <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A' ❑ New System <br />7Re facement System <br />p <br />❑ Treatment/Holding Tank- Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. ❑ Permit Renewal <br />11Permit 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 POINITS S stem/Com onent/Device: (Check all that apply) <br />N'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. Dis ersal/Treatment Aren Information: <br />Design Flow (gpd) <br />Design Soil Application Ratc(epdsf) <br />Dispersal Area (sf) <br />Dispersal Arca Proposed (sf) <br />System Elevation <br />/jRequired <br />t` <br />VI. Tank Info <br />Capacity in <br />Total <br />'of Manufacturer <br />Gallons <br />Gallons <br />Units <br />a <br />v <br />New Tanks EcistingTanks <br />o <br />HA <br />Septic or Holding Tank <br />VV <br />Dosing' Cham6cr <br />75O <br />VII. Responsibility Statement 1, the undersigned, assume responsibility for installation of the P014'TS shown on the attached plans. <br />s Namc (Print) <br />Pl70&1 <br />Plumber's Si <br />MPiMPRS Number <br />Business Phone Number <br />em S AI 2I" <br />$S �S�-' <br />7i5' �G� -oZo z. <br />Plumber's Address [Stn et, City, State, Zip Code) <br />7ZGiRcli <br />5 lJ 5C,9 <br />Vv� <br />VIII. CountyMepartment Use Only <br />Approved <br />A <br />C1 Disapproved <br />I <br />PCnnit Fee <br />Date Issued I <br />Issuing Agent Sim re <br />C3Owner Given Reason for Denial1� <br />IX.. Conditions of Approval/Reasons for Disapproval <br />DECEIVE <br />Attach to complete plans for the system and submit to the Count• onlg on paper not less than O t chez in srze <br />AUG 13 2018 <br />SBD -6393 (R. 11/11) IU <br />BURNETT COUNTY <br />7t7NIN(. <br />