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commerce.wl.gov Safety and Buildings Division Countyp <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> �sconsin <br /> Madison,W1 53707-7162 <br /> Sanitary Permit Number(to be Edled in by Co.)oepnrtmam of Commerce -521015 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with a.Comm.83.21(2),Wis.Adm Code,submission of this form to the appropriate governeremal 'ro' <br /> unit is requited prior to obtaining a sanitary permiL Note: Application forms for state owned POWTS are <br /> Address(ifdifferenttban mailing address) Vv <br /> submitted to [be Department of Commerce. Personal informatmn you Provide may be used for secondary <br /> purposes m accordance with the Privacy Law,s.15. 1Xm,Stats. r� <br /> L Armficatioa lnfor codon-Please Print AB Information ��` /03 1vc'.e)' <br /> Properly Owner's Name <br /> t7O r Lan Not - W.5-09 - Ole,,Ole,, 3vO <br /> R <br /> Prop Owner's Mailing dress <br /> 6• 9 �O X S piOPerlY Location <br /> City,StateGovt Lot <br /> Zip Code Plane Number Y. Y., Section /O <br /> Webs Frr w� Sya9� 7,s-- as 9- -74A 3 (circle oney <br /> IL Type of Building(check all dust aPP1Y) q Lot# T 4(9:p N; R /S-' E o fel <br /> l or 2 Family Dwelling-Number of Bedrooms rA 233 Subdivision Name <br /> Black#❑ JAR Pa>K A0thT'jZ40 PublidCommrncial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number U village of <br /> 1 'Town of kafo n <br /> Ill. t: (Cheek only one box on tine A. Complete tine B if■pplimble) <br /> ❑Replacement System TrealsrrnFL VH.WgTk Replacement Only ❑Other Modification m Existing System(explain) <br /> ewal UPermitRevision ❑Change ofPhmber ❑permit TfNLi at Previous Permit Numbermd Date Issued <br /> .0. eoPOWTS S stem/Com eat/Device: Chedt all that apply) <br /> ✓ T /i / 9/ <br /> Non-Preanmized In-Ground U Pressurized hr-Gmund U At-Gabe U Momd>2t in.of suitable soil ❑Mound<yy in,of suitable soil <br /> ❑Holding Tank U Other Dispersal Component(explam) U Pretreatment Device(explain) <br /> V. erssl)7v,eatmeat Ares lnformatim: <br /> Design Flow(gpd) Design Soil Application Rate(gpdet) Dispersal Atea Required(at) Die al Area <br /> per- Proposed(at) System Elevation <br /> X00 _ <br /> VL Tank Info Capacitym, Total #of Mamrfacmrer <br /> Gallons <br /> Gallons Units �Y c <br /> New re,ka Eslva T-do <br /> ct C7Q o <br /> g� <br /> Septic a Holding Twdc <br /> Do"Chamber /d00 /Oso TMS /pp0 / s,(iA..✓ <br /> VII.Bespr-nsibitity SMtement-I,the undetaigoed, <br /> name responsibility for installation ofthe POWTS shown on the attached plans. <br /> Humber's Name(Pint) Plumber's Signature MP/MPRS Number Business Hence Number <br /> RIC-/C ///o /c,.,s / f./ J•J.S'g'sr '7iS= ifbd-4/s� <br /> Humber'-Address(strc<t,city,State,Zip Code) <br /> d 7760 /.y/w3S W_e bsfr. W S Ygri 3 <br /> VIIL Coun /De "!meat Um <br /> IZ Approved U Disapproved Permit Feee, Date <br /> eIissued �Q In ' Si tons <br /> ❑Owner Given Reason for Denial E '300V /3 <br /> IX.Condid"of ApprovaURemom for Disapproval <br /> i <br /> J14Y 1 2 200 <br /> Atbeh to roapMe place for the syWa and mbslt tithe <br /> C^atiY anlym paper rotlea alrs:il loebnmdre <br /> BURNETT COUNTY <br /> SBD-6398(R.01/07)Valid thru 01/09 ZONING <br />