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Industry Services Division County <br />/ 4 1400 E Washington Ave <br />A <br />it ;, P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />\b Madison, 117 53707-7162 <br />l�C 3 <br />Sanitary Permit Application State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate govmenemit '�A <br />is required prior to obtaining a sanitary permit. Note: Application forms for state owned POWYS are submitted to erntal <br />the Department of Safety and Professional Services. Personal information you provide Project Address (if different than mailing address) <br />Purposes in accordance with the PrivacyLaw, s. 15.0 I m , Stats. Y may be used for secondary y� <br />L Application Information - Please Print All Information -75 q j RCL(; 0 L4et p <br />Property Owner's Name J <br />City, State ~ <br />Zip Code Phone Number <br />II. Type of Building (check all that apply) Lot # <br />�fi or 2 Family Dwelling - Number of Bedrooms <br />❑ Public/Commercial - Describe Use <br />❑ State Owned - Describe Use <br />Block # <br />Iu, ,,� �� 7� S <br />III Type of Permit. (Check only one boa on line A. Complete lice B if appli51 <br />A. <br />❑ New System I Replacement System ❑ Treatment/Holding Tank Replacement Only <br />B ❑ Permit Renewal ❑ Permit Revision <br />❑ Change of Plumber ❑Permit Transfer to New <br />Before Expiration (hr4r <br />0 -0.3G— 41/.-/k-3.3-5 Os <br />Property Location �3_ 0 Zz/L <br />Govt. Lot 3 <br />Section -33 <br />(circle one <br />T _N; RlbEo W <br />Subdivision Name <br />11 City of <br />❑ Village of <br />Town of (,(� <br />❑ Other Modification to Existing System (explain) <br />List Previous Permit Number and Date Issued <br />ci Nat -Pressurized In -Ground ❑ Pressurized In -Ground <br />❑ At -Grade ❑ Mound > 24 in. of suitable ❑ <br />Holding Tank <br />❑ Other Dispersal Component (explain) <br />- <br />soil Mound < <br />24 in. of suitable soil <br />❑ Pretreatment Device (explain) <br />V. Dis rsal Treatment Area Information: <br />Design Flow (gpd) <br />• <br />� 0 n <br />1-206) <br />Design Soil Application Rate(gpdst) <br />Di <br />Dispersal Area Required (sfJ <br />Dispersal Area Proposed (sf) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total # of <br />Manufacturer <br />Gallons <br />Gallons Units <br />:? 6 <br />New Teaks Existing Tanks <br />j y <br />Siaptie eFtloldiag Tank <br />> z <br />0. U uny Or) <br />X, <br />VII. Responsibility Statement- [,the andersigned, as me ' osibitity for installation of the POWTS shown on the attached plana <br />Plumber's Name (Print) Plumber Si <br />mp/mNCNumber Business Phone Numb <br />Plumber's AddressS����/ <br />( treet, City, State, Zip Code) <br />9306 8LACK a�00r, Imo. 0 <br />Viii f-- ---_!A_ -- _ _ _� <br />Approved ❑ Disapproved Pa t FFjee Date Issued Issuing Agent Signatu <br />❑ Owner Given Reason for Denial $ 3 / `S ' 0 7 /lp -/F' <br />IX[.�CCondittiions of Approval/Re/a�sonnss for Disapprooval�/ �� <br />l/it/O� (,GL/1 CJ /1 / 5 r/� � !/ coif// � -I /V S/Ci ``P <br />EC <br />AttaeL to eompkh ld� ror the system uud s.b,a.t to the Coaaty wdy wEF <br />qnr not kss <br />Pope I1 ieu°hes in sire <br />SBD -6398 K 08/14) <br />JUL 0 9 2Q18 <br />BURNE'TT COUNTY <br />ZONING <br />