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County <br /> Safety and Buildings Division 64 1A �G7T <br /> 11 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be tilled in byladdress) <br /> Madison,WI 53707-7162 <br /> S599 7�3 <br /> Sanitary Permit Application State Transaction Number <br /> errr <br /> In accordance with SPS 383.21(2) Wis.Adm.Code,submission of this form to the appropriate governmental unit L/rlrlt' 4UI <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 <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 that.Stats. 3 //�� o(evl L/C <br /> L .4 lication Information—Please Print.All Information <br /> Property Owner's Name Parcel#O'7� <br /> 011 - CasWboa 35 /S- doe- 0//000 <br /> PrroopertyOOwner's Mailing Address /` Property Location <br /> -!11 � O er✓' w ie N l.r Govt. Lot <br /> City,State Zip Code Phone Number y,,V., Section 3 <br /> Ro.Sem OI.s N+ m IV .&rc 6 g (circle one <br /> T Zle N, R�& E o <br /> 11.Type of Building(check all that apply) �1 Lot# <br /> �(I or 2 Family Dwciting-Number of Bedrooms 7 —Z Subdivision Name <br /> Block Fe—as 5UIVJS/Dh Or ak- <br /> ❑Public/Commercial-Describe Use <br /> ❑ Ciry of <br /> El Stare Owned-Describe Use CSM Number El Village of <br /> b(7Townof 0i;9/and, <br /> 111.Type of Permit: (Check only one box online A. Complete line B if applicable) oa --� —lop <br /> A <br /> El New System K Replacement System ❑Treatment/Holding Tank Replacement Only El Other 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 System/Component/Device: (Check all that apply) <br /> N Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 inof suitable soil ❑ Mound,24 inof 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 RateUmdsU Dispersal Area Required(st) Dispersal Area Proposed(St) System Elevation <br /> too0 . 7 gs8 ?6ef 9d. 0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v v <br /> New"ranks Existing Tanks <br /> Septic or Holding Tank / SO 99-0 <br /> Dosing Chamber 11 <br /> Vll.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the PON'TS shown on the attached plans. <br /> Plumber's Name(Print),/ Plumber's Sianature MP/MPRs Number Business Phone Number <br /> RI C-(C /7o P/Clrf / � 1 � ,tdsfrs 1 -113- 6"(01 yfS`7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ) 774O 14— 3S <br /> VII .County/De artment Gse Only <br /> Approved ❑ Disapproved perrmittFee y � Date Issued �J Issuing Age _ arm- <br /> [I <br /> zure <br /> [IOwner Given Reason for Denial 1_-32!ee"^_ <br /> IS.Conditions of Approval/Reasons for Disapproval M <br /> OCT 4 2012 <br /> Attach to complete plans for the sastem and submit to the County only on paper not less than 8 1 1 ches in size <br /> BURNE17 COUNTY <br /> SBD-6398(R. I1/11) <br /> ZONING <br />