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County <br /> / ! �`•+ Safety and Buildings Division 03 r in m-ff <br /> :'tt 0 r' 201 W. Washington Ave., P.O. Box 7162 <br /> i S rl g Sanitary Permit Number(to be filled in by Co.) <br /> PS fir Madison,WI 53707-7162 <br /> Application <br /> State Trmsaetion Number <br /> Sanitary Permit Appii <br /> 1 v' <br /> In accordance with SPS 383.21(2),W is-Adm.Code,submission of this form to the appropriate governmental unit ump 1 P(.r� <br /> is required prior to obtaining a sanitary permit Note Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary <br /> u ses in accordance with the Privacv Law,s. 15.04(1 Nm),Stals. / P�K <br /> I. Application Information-Please Print All Information v <br /> Property Owner's Name Parcel#- <br /> w# 05- oolo - a//490/ <br /> ­ <br /> Property Owner's Mailing Address Property Location <br /> Sot y Govt Lot '/ 1 <br /> City,State Zip Code Phone Number '/,, R /G <br /> /V� w / f ,, Section <br /> 6a/e-1A (e M A (circle one <br /> lf.Type of Building(check all that apply) Lot# T �/O N, <br /> 91 or 2 Family Dwelling-Number of Bedrooms � Subdivision Name <br /> Block d <br /> 0 Public/Commercial-Describe Use <br /> ❑ Ciry of <br /> 0 State Owned-Describe Use CSM Number 0 Village of <br /> �Townof �16G(�•SO y.t <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `*' K New System 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. L1 Permit Renewal ❑ Permit Revision ❑Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: (Check all that apply) <br /> ,}yon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound 124 inof suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> N.Dispersal/treatment.area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 14so - 700 <br /> 9oa s31, 20 <br /> NT Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units _ ti <br /> New Tanks Existing Tanks - <br /> U <br /> Septic or Holding Tank 00 /(l00 <br /> Dosing Chmnbtr O v �av <br /> VII.Responsibility Statement- I.the undersigned,assume responsibility for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's/Signature <br /> � MP/NIPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State-Zip Code) <br /> 776d 1<4 3S— Gv-e 5)(-r— <br /> Ar <br /> VIII.County/De artmen[Use Only <br /> Approved 0 Disapproved PermitsQFee Date II�sssued Issuing As, gnature <br /> 0 Owner Given Reason for Denial g3/C5��11 �6�o�2ev2 <br /> LC.Conditions of Approval/Reasons for Disapproval M- <br /> En <br /> Attach incomplete plans for the stem and submit to the County onb'on paper not less than 8 i/U IUehU ne <br /> BURNM COUNTY <br /> sBD-6398(R. n/I a ZONING <br />