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County <br /> Safety and Buildings Division VtAlelli <br /> D = 201 W_Washington Ave.,P.O.Box 7162 Sar_ Paingtt lv�uatb¢(to be filled in by Co.) <br /> .s S ( j Madison,WI 53707-7162 <br /> Sanitary Permit Permit Application NuIrr <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate goverumcntal unit G O V AI75 ✓.,e k., <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if difrerent than mailing address) <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.15.04(1)m,Stats. �� <br /> I. Application Information-Please Print All Information <br /> 6 47J Ff <br /> Property Owner's Name parcel# <br /> Property Owner'ss[Mailing Address Property Location <br /> � T G�� Govt.Lot <br /> City,State Zip Code Phone Number /, y,, Section z <br /> 1 YrItll I'rL�^Z� T N0 N: R r f E� <br /> H.Type of Builth g(check all that apply) Lot# <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 ❑Village of <br /> ®Town of K)IV 6 CA/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A' ❑New System Re lacement System <br /> ❑Treatment/Holding Tattle Replacement Only ❑Otter Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S tem/Com nent/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> *gHolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks ei v o <br /> G U in w to i=O 4 <br /> Septic or Holding Took d 7/tt) z w <br /> Dosing Chamber �'�"V <br /> VII.Responsibility Statement-1.the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum s Name(Print) / Plumbers titre MPiMPRS Number Business Phone Number <br /> og� ei ndo,- % 1851?27 <br /> Plumber's Address(Street,City,Sate,Zip Code) / <br /> Z 7ZZv `�4�r,t�.�A6 t4el.,I-tw^ t..l S�Bp <br /> VRI.County/Department Use Only <br /> Approved ❑Disapproved PermitFCCDate Issued issui Age t S' re <br /> [3Owner Given Reason for Denial 'J7�O© 11-H-1& <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> �e 933.D' t VeAI Ned %v a or <br /> ""Ore <br /> Attach to complete plans for the system and submit to the Couah•only on paper out I®than a urs x fl in P=r <br /> SBD-6398(R.11/11) NOV 14 2016 <br /> BURNETT COUNTY <br /> 7ntulnlfn <br />