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Attach to complete plans for the system and submit tothe County only on paper not less than 8 JJx I l Uches in s;e 1)10 I �� <br />BURNETT COUNTY IL��// <br />SBD -6393 (R03 13) ZONING <br />Industry Services Division <br />County �H. V 1� •G� <br />Yi <br />1400 E Washington Ave <br />R0. Box 7162 <br />Sanitary Permit Number (to be tilled in by Co.) <br />=i <br />N — <br />'s <br />Madison, WI 53707-7162 <br />--77 <br />Sanitary Permit Application <br />State Transaction Number <br />12114— <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate govermnental 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 />I & s'�rtl <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />r- t 0 1''N 16 <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel 1 _.4-39-4-07-3 �� <br />��d y CY t NCU.YN GE Vt <br />DGOO — �/30d0 <br />Property Owner's Mailing Address <br />Property Location <br />dNoe <br />Govt. Lot <br />AJW y, .1 yV_ y, Section % <br />City, State <br />Zip Code <br />Phone Number <br />y •t I'Y1 <br />.S�rSD D 3 <br />cuc one <br />T .39 N; R E or� <br />Crle <br />Ii. Type f Building (check all that apply) / d <br />r �S t <br />Lot # <br />Subdivision NameBlock <br />1 or 2 Family Dwelling — Number of Bedrooms W i 1k 701 !tet <br /># <br />❑ Public/Cotmnercial —Describe Use <br />❑ City of <br />❑State Owned —Describe Use <br />❑ Village of <br />CSM Number <br />Town of Al -d 0 h <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A, <br />�ew System <br />❑ Replacement System <br />❑ Treannent/Holdin� 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 />IV. Type of POWTS S stem/Com onent/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 />Fioldin ;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) <br />System Elevation <br />-3& t) <br />--- <br />— <br />-- <br />— <br />VI. Tank Info <br />Capacity in <br />Total <br /># of Manufacturer <br />Gallons <br />Gallons <br />Units <br />o <br />New Tanks <br />Existing Tanks <br />o <br />aU <br />v E <br />'r,;ul <br />Y <br />ciU <br />a <br />Septic or Holding Tank <br />410017,4-0 <br />01,ge0 <br />Slyer✓ li <br />/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 />/fir <br />7�.i = �!/S- 7 <br />u c h�oe<�-Sf1.s'"/ <br />Plumber's Address (Street, City, State, Zip Code) <br />77; 0 1 W�7_ S�J 3 <br />VIII. Coun /Department Ilse Only <br />Approved <br />11 Disapproved <br />Permit Fee 60 <br />Date Issued <br />Issuing Agent Signa e <br />ElOwner Given Reason for Denial <br />$ 37S <br />! �6 <br />IAC. Conditions of Approval/Reasons for DisapprovalAPPROV[D pp / <br />p <br />/110 %� 4'e �%ted 4o✓ ECEIV/ E <br />n. <br />-..P , 7 -)n,o rL <br />Attach to complete plans for the system and submit tothe County only on paper not less than 8 JJx I l Uches in s;e 1)10 I �� <br />BURNETT COUNTY IL��// <br />SBD -6393 (R03 13) ZONING <br />