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•-••••-•• •� .,,...r.�..: i......� .......� ,r,•........., ,.. •,.•... ,., •u< <.uuuty umy on paper not Less roan U2 x El inches in size �..../ <br />BURNETT COUNTY <br />SBD -6398 (110313) <br />ZONING <br />Industry Services Divisions <br />Court <br />r vt -C <br />`t Sp P <br />1400 E Washington Ave <br />SanitaryPermit Number to be tilled in b Co.) <br />( y <br />Sj <br />P.O. Box 7162 <br />l� <br />trF <br />Madison, WI 53707-7162�—L�3 <br />Sanitary Permit Application <br />State Transaction Number <br />StNA <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 Servies. Personal information you provide may be used for secondary <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />1. Application Information – Please Print All Information <br />Property Owner's Name <br />Parcel # <br />*- d e0—/ & <br />�v'Cc (9ls�h <br />0-7-©d <br />r5o3 -©td loo <br />Properb- Owner's Mailing Address <br />Property Location <br />7 8 70 CO ;r,, <br />3 <br />� f <br />Govt. Lot <br />y,, y., Section A 61 <br />City, State Zip Code <br />Phone Number <br />*4_9 re r '-Y Sr3 <br />7/S- 5l /G.33d <br />(circle one) <br />Z/ (circle <br />T N; R _— E o <br />II. Type of Building (check all that apply) <br />Lot # <br />❑ 1 or 2 Family Dwelling – Number of Bedrooms <br />7 <br />Subdivision Name <br />Block # <br />❑ Public/Commercial –Describe Use <br />❑ City of <br />❑ State Owned – Describe Use <br />❑ Village of <br />CSM Numbaa�t-3 <br />93 <br />V.d A <br />fR' Town of .SCG <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A' <br />❑ New System <br />Ill. Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />El Permit Renewal <br />❑Pennit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />/� ✓,` <br />IV. Type of POWTS System/Component/Device: (Check all that apply) <br />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. Dispersal/Treatment Area Information: <br />DesignFlow d) <br />Design Soil Application Rate(gpdst) <br />Dispel Area Required 00 <br />Dispersal Proposed (st) <br />SyestteemEle tion <br />� <br />0e <br />l <br />C <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />0 9 <br />New Tanks Existing Tanks <br />w r Y <br />o - 2 <br />c, U M y Cn <br />i,. V <br />a <br />Septic or Holding Tank <br />��©L% <br />l <br />I , I / ✓ <br />!N �C <br />Dosing Chamber <br />VII. 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 />MP/MPRS Number <br />Business Phone Number <br />Plumber's Address (Street, City, State, Zip Code) <br />a 776D mss' At - 6,57,-e, <br />VII. County[Departmenf Use Only <br />Approved <br />Disapproved <br />Pennit Fee <br />$ <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />37� <br />19- <br />-X. <br />X. Conditions of ApprovaUReasons for Disapproval <br />ECEWE <br />AP PROVED q[n) <br />SEP 19 2018 <br />•-••••-•• •� .,,...r.�..: i......� .......� ,r,•........., ,.. •,.•... ,., •u< <.uuuty umy on paper not Less roan U2 x El inches in size �..../ <br />BURNETT COUNTY <br />SBD -6398 (110313) <br />ZONING <br />