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s Industry Services Division County <br /> 1400 E Washington Ave (}f� <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> _ Madison,WI 53707-7162 AOA`' <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 governmental unit <br /> S"U(f <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than maih'ng address) <br /> the Department of Safety and Professional Services.Personal Information you provide may be used for secondary 04' �� /l�1�,.�,Jeclo( or <br /> purposes in accordance with the PrivacyLaw,s.15.04(1)(m),Slats. ii,cc � <br /> I. Application Information-Please Print All Information �!un/I� tt r' va 5*3,44W <br /> Property Owner's Name Parcel# <br /> e` am %ffa J 07- 09-V-o? -37-1 aiAn t7 <br /> Property Owners Mailing Address Property Location <br /> I'Cet Ve Govt.Lot <br /> City,Stat0V <br /> ,� / Zip Code Phone Number V4 y4, Section <br /> Sf. I fi /V 5 /b ' -^� -7 �"�/� (circle one <br /> (� l �Q T r N: R_It E or w <br /> H.Type of Building(check all that apply) 1ot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number /jo ❑ Village of ),. <br /> C51 ` 1/ VlA PCfJ! ?.Town of JtC <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' New System <br /> y ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. Permit Renewal ❑ Permit Revision Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> 13Xore Expiration Owner 7017 <br /> IV.Type of POWTS System/Component/Device: Check all that app1 <br /> ❑ Non-Pressurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> 9 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis rsal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(s i System Elevation <br /> ub to s�i-00 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units V o <br /> New Tanks Existing Tanks v 'J Ua y A <br /> a U in h to is. U o <br /> Septic or Holding Tank A <br /> Dosing Clamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address Street,City,State,Zip Code) <br /> 711 -?Urh <br /> VIII.Coun /De artment Use Only <br /> pproved El Disapproved Permit Fee Date slued 1 mg gent Si lure <br /> El Owner Given Reason for Denial 75. <br /> 1O /q <br /> IX.Conditions of ApprovaMeasons for Disapproval <br /> APPROVED <br /> ECMVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x 11'nc a 'n size <br /> JUL 18 2019 <br /> BURNETT COUNTY <br /> SBD-6398 (R.08/14) ZONING <br />