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ON COMPUTERISCANNED <br />Itz'' <br />"- <br />Industry Services Division <br />County - <br />1400 E Washington Ave <br />Samt ry Permit Number to be tilled in by Co.) <br />P.O. Box 7162�� <br />I <br />K/ <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <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 PO WTS 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), Stats. <br />111-eadacv G✓t,en /�oP' <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # o y_ p7- <br />�s7-odr- d -Y <br />Rah elr to ria 1, <br />y8C - o yYaoo <br />Property Owner's Mailing Address <br />Property Location <br />-7dd l E Ea/ c wV6W 4V 16 <br />Govt. Lot <br />y, /4, Section 7 <br />City, State <br />Zip Code <br />Phone Number <br />e Q 14z <br />O 8 <br />(circle one) <br />T �f0 N; R �� E or�% <br />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />-9 l or 2 Family Dwelling - Number of Bedrooms <br />C v V❑Public/Cotmnercial <br />Block # <br />-Describe Use <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />W Town of .SGO <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />New System <br />11 Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />El 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 rn-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 />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) System <br />Elevation <br />�sd <br />yid S <br />dy y ss <br />o 9y 9y y <br />VI. Tank Info <br />Capacity in Total # of Manufacturer <br />Gallons Gallons Units <br />U <br />New Tanks Existing Tanks w° <br />_ <br />c <br />U v] <br />ul <br />Septic or Holding Tank <br />I6.rr� <br />/ �- <br />W -C) AA",/ .Z1N /�Pa 710, / 'y <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�Signatu <br />MP/MPRS Number <br />Business Phone Number <br />Plumber's Address (Street, City, State, Zip Code) <br />77,00 1.1Z <br />,w., _Rr <br />VIII. Coun /]Department Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />$ <br />Date Issued <br />Issuing Agent Signatur <br />❑ Owner Given Reason for Denial <br />t7 76— <br />IX. Conditions of Approval/Reasons for Disapproval <br />(�' <br />� `�Y��% <br />C E <br />t� l5(C em� <br />Attach to complete plans for the system and submit to the County only on paper not less than S 1/2. tin es in <br />BURNETT COUNTY <br />SBD -6398 (R0313) ZONING <br />