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BURNETT COUNTY <br />ZONING <br />- .:* <br />Safety and Buildings Division <br />County <br />urw' <br />201 W. Washington Ave., P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />13 <br />IF <br />Madison, Wl 53707-7162 <br />Sanitary Permit Application <br />State Transaction Xtumbcr <br />StNAIn <br />accordance with SPS 383 21(2), Wis. Adm. Code, submission of this form 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 POWTS 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. Stats. <br />�I k <br />I. Application Information — Please Print All Information <br />ar <br />Property Owner's Name <br />Parcel # <br />bre r <br />Property Owner's %Mailingg ddress <br />Property Location <br />&53— :;Ffvvfj- 6�we_ 'ML <br />Govt. Lot <br />V., Section t <br />City, State <br />Zip Code PhoneNumb <br />41-7- <br />VV '76 <br />Jgircic one) <br />T N; R /45 E or <br />11. Type 6`17 Building (ch ck that apply) Lot', <br />Subdivision Name <br />II or ?Family Dwelling —Number of Bedrooms <br />BlockE <br />0 Public/Commercial — Describe Use <br />0 City of <br />0 State Owned — Describe Use CSM <br />0 Village of <br />Number <br />V/8 <br />P167 <br />5tr-um of I <br />111. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A, <br />11 New System <br />NrReplacement System <br />11 Treatment/Holding Tank, Replacement Only <br />Other Modification to Existing System (explain) <br />B. <br />13 Permit Renewal <br />0 Permit Revision <br />13 Change of Plumber <br />El Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />I Owner <br />9-3-27 <br />IV. Type of P01VVTS SystemlComportentlDevice: (Check all that apply) <br />9rNon-Pressurized In -Ground 0 Pressurized In -Ground 0 At -Grade 0 Mound > 24 in. of suitable soil ❑ 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 />Desi Flow (gpd) <br />Design Soil Application Raic(_p-pdsf) <br />Dispersal Area Required (sD <br />857 <br />Dispersal Area Proposed (sf) <br />85% <br />System Elevation <br />%9Z,D9f 6 <br />V1. Tank Info <br />Capacity in <br />Total <br />rof <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />U <br />New Tanks Ecistinge Tanks <br />Septic or Holding Tank <br />/zoo <br />7TO <br />Dosing Chamber <br />VH. Responsibility Statement- L the undersigned, assume responsibility for installation of the P0`V4TS shown on the attached plans. <br />Pluems Name (Print) <br />Plumber's <br />MPJMPRS Number <br />Business Phone Number <br />oz <br />Plumber's Address (Struct, City, State, Tip Codc) <br />F _j " <br />-7z-70 <br />VIII. County/De artment Use Only <br />Approved <br />0 Disapproved <br />Permit FCC a <br />Date Issued <br />Issuing Agent Signature <br />0 Owner Given Reason for Denial <br />S 4PI <br />I <br />--f <br />Ii. Conditions of Approval/Reasons for Disapproval <br />IPPROVED "MVE <br />EC <br />I n� <br />.-Utach to complete plans for the system and submit to the County only an paper not less than 3 M I W <br />_077c-s�srize <br />R JUL 2 3 2018 <br />U) <br />BURNETT COUNTY <br />ZONING <br />