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ON COMPUTER/SCANNED <br /> y+ ''g' '�i'• County <br /> `#N, Industry Services Division <br /> � 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> 4�Sp P.O. Box 7162 �J <br /> Madison, WI 53707-7162 / 9 <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 000-ro,/ e 1/r?kv <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 Smies. Personal information you provide may be used for secondary b No <br /> purposes in accordance with the Privacy law,s.15.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information 1(60hey 04 Rd <br /> Property Owner's Name Parcel# <br /> 7,Od <br /> 0 08- o�yioo <br /> Property Owner's Mailing Address 1roperty Location <br /> /S3�Q �rstYl'�'(YS 4" (ft c- e- All Govt.Lot o <br /> City,State Zip Code Phone Number <br /> /<, Section <br /> f4;11 Lv'OL'I41✓ In /V sSOB.i b Q- 3 ar 4S`_�Q (circle one) <br /> .Q.Type of Building(check all that apply) Lor# <br /> T 4P N; R��Ea <br /> IXt I or 2 Family Dwelling-Number of Bedrooms 3 ?v Subdivision Name <br /> B lock# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of_ <br /> ❑State Owned-Describe Use CSJvvl Number q❑ Village of <br /> \ <br /> Y 01)3 Q I� o Town of jre- <br /> t <br /> II1.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A, New System y ❑ Replacement System ❑ TreaunenVHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Penmit'rransfer to New List Previous Pennit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stemlCom onent/Device: KCheck all that apply) <br /> XNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> also ,S� Or" 90o 93, <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a " o <br /> New Tanks <br /> Existing Tanks " U v `^ <br /> c. U u� y in ii V a <br /> Septic or Holding Tank W I rs Y` <br /> Dosing Chambar <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /zl G le 19a)a lei n S <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77teO e< 3s 4/4�s F:. G✓1 �y8s3 <br /> VIII.Cour /De artment Use Only <br /> yp Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signa ire <br /> Y� ❑ `Owner Given Reason for Denial $v�J'f/ <br /> IX.Conditions of ApprovallReasons for Disapproval f <br /> /ryu,fl//dtiN{;nJ 3t or /No/'C SCT liaC /Root- �ro��rlry 1,""f5 V/ <br /> i�'e lt� np n <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Ih x me in sbtij 13 2016 <br /> BURNETT COUNTY <br /> SBD-6398(R0313) ZONING <br />