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BURNETT COUNTY <br />SBD -6398 (R0313) ZONING <br />Industry Services Division <br />County <br />;Xi- ai _ �r <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Sanitgry Permit Number to be filled in by Co.) <br />.$' <br />Madison, WI 53707-7162 <br />u lrJ <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, subrrassion of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />the Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br />310/ <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />-Padowr &.,e e, t AOP' <br />I. Application Information — Please Print All Information <br />/N <br />Property Owner's Name <br />Parcel # p7- -t.? <br />07—o,t8�d - oY�t000 <br />l�Ohe,.r F4-1,44 <br />We <br />Property Owner's Mailing Address <br />Property Location <br />6-,45'. W o 004 �%v >� <br />Govt. Lot <br />Y, /,, Section 7 <br />City, State <br />Zip Code <br />Phone Number <br />m eS Q. d Z s- <br />/7 <br />8 <br />(circle one) <br />T qV N; R �� E orp <br />H. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />Ior2Family Dwelling — Number ofBedrooms <br />(0 <br />k 6.1m.., v ✓, <br />Block <br />❑ Public/Commercial — Describe Use <br />❑ City of <br />El State Owned —Describe Use <br />❑ Village of <br />CSM Number <br />W Town of See 7f <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />{� New System <br />❑ Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B• <br />El Renewal <br />❑Permit Revision <br />Change of Plumber <br />b <br />11❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS System/Component/Device: (Check all that apply) <br />Nd.-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. Dis er- I/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdst) <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />LlSO <br />• `'f <br />N .S_ <br />//3 Y <br />VI. Tank Info <br />Capacity in <br />Total # of Manufacturer <br />Gallons <br />Gallons Units , <br />New Tanks Existing Tanks <br />�,�, o v Y <br />c. U m I;; rn <br />Cd <br />Septic or Holding Tank <br />Dosing Chambzr <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signatu <br />MP/MPRS Number <br />Business Phone Number <br />Plumber's Address (Street, City, State, Zip Code) <br />LII. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Pen-nit Fee <br />$ <br />Date Issued <br />Issuing Agent Signatur <br />El Owner Given Reason for Denial <br />? <br />IX. Conditions of Approval/Reasons for Disapproval <br />( ( 0 <br />E' <br />n tom ILm �7 <br />V <br />D <br />n <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 . 1 in es in <br />BURNETT COUNTY <br />SBD -6398 (R0313) ZONING <br />