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RTA <br /> r Colnty---- --- <br /> �•c <br /> Safety and Buildings Division <br /> 201 W.Washington Ave., P.O. Box 7162 San ' ( <br /> tary ermlt umber to be filled in by Co.)� <br /> i C7. Madison,Wl 53707-71 G2 <br /> -7D �I�91Df <br /> SauitarY Pen-nit Application —_ Stare Transaction Number <br /> in accordance with SPS 383.21(2),Wis,Atkin.Code,submission of this form to the apptopriate governmental Unit / <br /> is required prior to obtaining a sanitary permit. Note.Application forms for state-owned POWT:S are submitted to Project Address(if dAi'ffA,ert�Ktj than mailing address) <br /> thr DepRitment of Safety and Professional Servies. Personal information you provide may be used for secondary �7� AL PM <br /> purposes in accordance with the Privae Law s. ].5.04(1i Stats, _ <br /> l._A(►pliratio►n Infmrmation_-Please Print Al}Information�— - e(3 1 <br /> Property Owner's Name _.__.___..__ _ <br /> i' <br /> Parcel/! CIA,_3.?a200- -0 S�v <br /> 7-0_4-0 39 f��6 �.t <br /> Proparty Owner's Mailing Address —" - ---- Property Location (' 06e, <br /> Govi.Lot <br /> City,Sttnc Zip Code Phone Number <br /> .WA '/,,� '/, Section <br /> i�_ (circle one) <br /> l apply)i.Type of Building(check all that a l Lot# ----- - T N; R /�--E or W <br /> 1 of 2.}amity i Ewe <br /> ll' lling-Ntmrbcr of Bcrlrooms__,� Subdivision Name <br /> I_)}'uhliclC:ommerrial--Desrribr.Use <br /> ❑City <br /> StairOconed-- Deecriheilse._ — CSMNumber ❑Village of <br /> ---- — --------------- <br /> Town of_ ro ee ey0 �l� <br /> ill.'l'ype of Permit: (Check only one box online A. Complete linen if applicable) --`----- _- <br /> f New System ❑.Replacement System ❑Trr atineltt/1-lolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> 14• ❑Permit Renewal D Permit.Revision ❑Change of Plumber ❑permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> _lV,-'l'_ype t<f�'l3W'l'S System/CompanentlDevice: (Check_afl that aAp1v)-- _ - .— -------- <br /> KNon-Pressurized In-Ground ❑ Pressurized in-Ground 0 At-Orade []Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil — <br /> j-i 1lolding'Fank 1.1 Other Dispersal Component(explain)__,--_-_____ Pretreatment Device ldi -- - <br /> V 1)ipersa}/Tr rntnaent Area Informations `--- —--- ---- - - <br /> resign HOW(gpd) Design Soil Application Ratc(gpdsf) Dispersal,Area Required(sf)T Dispersal Area Pr*Sy;� tion -S ��6 � �0QV1.Tank,11tfo Capacity is T'otal /1 of- -- -- Manufacturer <br /> Gallons UnitsLxisting Tanksm --- <br /> AlK Responsibility Statement- 1,the.undersigned,assume reAponsibility for installation of the POW'.CS shown on the attached plans. <br /> Plumber's Name.{Print) - P}umber's Signature — <br /> - — <br /> RS Number Business Phone Number <br /> I'lumber's Adfhrss(Street,City,State,Zip Code) - <br /> iQC/lyC H i <br /> -----------t� <br /> Vlil. Coant�l)e artment Use Only ----- <br /> ------ ------- <br /> tproved �_� Disapproved Permit Pee Datc Limed Ly issttitt;Agee ignature <br /> LI Owner[liven Reason for Denial .> <br /> A.Conditions of Approval/Reasons for DisapprovalAPPROVED <br /> D <br /> Attach to co+aplcte plans for the syntem and submit to the Country only on PRper rut less than 8 It2 x 11 inch n s <br /> Burnett County <br /> 5I31)-t;a9R(R. l 1!1!) Land Services Department <br />