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»K *i� Coun[y <br /> Industry Services Division f`e N`4!' <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> PS P.O. Bax 7162 701 <br /> Madison, WI 53707-7162 <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 95;?9 C"o <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 Scrvies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. 3 <br /> L O 3d S CO Rw (� <br /> Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> IWI .Sfere 07-038-1 H� fK-��-A <br /> M <br /> 02-000-O/4 006 <br /> Property Owner's Mailing Address Property Location <br /> 363ag co Rd <br /> Govt LPt—,�— <br /> City,State Zip Code Phone Number �� '/ Section <br /> W,eS6 L/G WX l f_?a (circle one) <br /> II.Type of Building(check all that apply) Lot# <br /> R AiV E o(f�' <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> IM <br /> Block# <br /> Public/Commercial-Describe Use /��YiQ1l S:�ore <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number a)08' ❑ Village of <br /> 4 ? 7 L�1 Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Chane of Plumber List Previous Permit Number and Date Issued <br /> Change El Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 im of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding 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(st) Dispersal Arca Proposed(sf) System Elevation <br /> y1l . 7 5'97 -7.+0 1 W.f, <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c c <br /> New Tanks Existing Tanks o y D a <br /> Septic or Holding Tank �eYj�3 e 0 /d►Op / W/.[J'�-.� )( <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /Z/ztk o k / � Wo a-�is7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7764 3j(__ t.0-e46S?e-e uJ—,5�_jf�g3 <br /> VIII.County/Department Use Only <br /> Ur Pennit Fee Date Issued Issuing A Signature <br /> Approved El Disapproved S ' <br /> ❑ Owner Given Reason for Denial 3151 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> !FEPVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than A in x it inc i ze <br /> ✓�� <br /> SBD-6398(R0313) BURNETT COUNTYZONING <br />