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' .v.vesr3. Safety and&*WVs1 ar _ - '�tAI /Yf eTT <br /> 201 W.WasFrngt n Ave_a.0,am TAM <br /> 41 <br /> Madison.Wl 53707-11� <br /> .5q4537 q , /53 <br /> C f. <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),R'is.Adm.Code.submission of this form to the appropriate gove.^.krsa; <br /> is required prior to obtaining a sanitary permit. Note.Application forms for state-owned POKTS are submirec <br /> the Department of Safety and Professional Sen ies. Personal information you provide may be used for second::. <br /> purposes in accordance with&-Pr1vaE y U% s. 15 04(l)(m),Stals. � I /: ,(�(/�(�(',n� /,1y�• _ si <br /> I. Application Information-Please Print All Information 6 11J V� r 1Vf <br /> Property Oss'rar's Narnr ��// Parcel <br /> Property Own e(s Alallimq \d're" Propem Locxr.�; <br /> r r Govt.Lot A_ <br /> City'. tat Zip Cork Phone Number <br /> T "J 1 N: RE. 1s <br /> I\ of Building(chick all that apply) Lot S <br /> " 'T <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block B <br /> ❑Public/Commercial-Describe Use <br /> ❑cit of <br /> ❑Stale Owned-Describe Use CSM Number ❑Village of <br /> ' ,Townof <br /> Ill.Type of Permit: (Check only one box on line A. Complete fine B if applicable) <br /> A. <br /> ❑New System ❑Replacement System xTreatmenc'Holdtng Tank Repiacer�wa Ord%- Other Modification to Existing System:.eX ; _ <br /> B. ❑Permit Renewal ElPermit Revision '_Change of Plumber I Permit Transfer to New Leri Previous Permu!cumber and Date Issuer! <br /> Before Expiration <br /> Owner . <br /> IV.Type of POWI'S S tem/Com nenUDevice: Check all that -- <br /> ❑Non-Pressurized In-Ground �_.Pressurized In-Ground _;At-Grade Q Mound>24 in.of suitable soil ❑Mound c 24 In.of suitable soil <br /> Holding Tank []Other Dispersal Component(explain) ❑Pretreatment Device(explain[ <br /> V.Dispersalfrreatiment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 0. <br /> VI.Tank Info Capacity in Total ii of : Manufacturer <br /> Gallons Gallons Units ° E <br /> Nese Tanks Fxisting Tanks m k U <br /> 1: 3 _ <br /> Septic or Holding Tank yo0 <br /> Dosing ChamMr ) <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans, <br /> Plumber's Name(Print) Plumber's Signature \4PTIPRS Number Business Phone Number <br /> 6,AIleA/ K 1fa^1SoN C oas7g3 71.5 /o f�/�© <br /> Plumber's Address(Street,City,State.Zip Code) <br /> I-71c a7or'r eve 1L-4-6-k w_T SY953 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee rDate Issued Issuing Agen Signature <br /> t 3� 5 a - 17 <br /> ❑Owner Given Reason for Denial <br /> IX OK-F iitiorrs of�fAppro. 6 NLL A v Q Sq vat <br /> R'msCXS /` 0 mc�'L o 2?C/ Leos 9 la .6 L►cyo--i`shy <br /> My .5 Mee.-T- .50 A A_r Xl, (-,.rich D ECEI V E <br /> Attach to Complete plans for the system and submit to tWe County only on paper not less than a to x 11 Inches In A JUN 2 3 2017 <br /> SBD.6M(R. 1In 1) BURNETT COUNTY <br /> ZONING <br />