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�'>a'a ri- <br />Industry Services Division <br />County <br />�u r n e �Ax oZ 303 <br />�yA <br />1400 E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />P <br />�� S <br />P.O. Box 7162 <br />Z?Madison, <br />*�,, ✓,�.� <br />WI 53707-7162 <br />Sanitary Permit Application <br />State Transaction Number <br />accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate goverrunental unit <br />11119— <br />vA—isIn <br />isrequired 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 />3 �© <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />I. Application Print <br />Information - Please All Information <br />Property Owner's Name <br />Parcel # <br />lq*rlrt �� Cl�low•f��� <br />Dy-000-D/Z/000 <br />Property Owner's Mailing AcMress <br />Property Location <br />?0 8G X 3 e � <br />Govt. Lot c� <br />Section o <br />City, State <br />Zip Code <br />Phone Number <br />< <br />0A N b fA el (Ny ,S dcircle <br />one <br />T y/ N; R /� E o <br />II. Type of Building (check all that apply) <br />Lot # <br />] <br />t or 2 Family Dwelling - Number of Bedrooms ^ <br />Subdivision Name <br />Block # <br />❑ Public/Cornmercial -Describe Use <br />❑ City of <br />❑State Owned -Describe Use <br />❑ Village of <br />CSM Number <br />XTown of ,Su�t.SS <br />II1. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B <br />❑ Permit Renewal <br />❑Pennit RevisionBefore <br />❑ Change of PlumberFE],,vPennit <br />Transfer to New <br />List Previous Permit Number and Date Issued <br />Exp ration <br />ner <br />a CP (0 p20 8 SAO <br />IV. Type of POWTS S stem/Com onent/Device: (Check all that apply) <br />❑ Non -Pressurized In -Ground Z Pressurized [n -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ HoldingTank ❑ 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 />300 <br />. S <br />Gbo <br />LY8 <br />9S' <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units n <br />o <br />p <br />- <br />New Tanks Existing Tanks <br />o <br />y <br />c <br />U vt� cn <br />w U e. <br />Septic or Holding Tank <br />Dosing Chamber <br />/ <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 />NIP/MPRS Number <br />Business Phone Number <br />// <br />Plumber's Address (Street, City, State, Zip Code) <br />� �7�0 ,S/w .�.� /�i'�6sr��•. �,�r.= .5-58 s 3 ` <br />III. Coun /Department Use Only <br />Approved❑ <br />Disapproved <br />PermitFee <br />Date Issued <br />Issuing Agent Signatur <br />ElOwner Given Reason for Denial <br />t)0 <br />3 / �' <br />(� <br />1�� �3� 'v <br />J Z 0� <br />IX. Conditions of Approval/Reasons for Disapproval <br />=GEOV <br />D <br />APPROVED <br />� Nnv <br />.attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 s 11 inc Us in ge <br />BURNETT COUNTY <br />SBD -6393 (R0313) ZONING <br />