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ON COMPUTERISCANNED <br />Attacn to compiere pians for ute system ana summit to the County only on paper not less than S 1/2 x ll inches it rzA1 , —J <br />BURNETT COUNTY <br />SBD -6398 (R0313) ZONING <br />Industry Services Division <br />County <br />�� ✓'� 'ems <br />0,- R + <br />�� <br />�"� <br />140Q E Washington Ave <br />Sanitary Permit Number (to be tilled in by Co.) <br />P� <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />f `- <br />���� <br />q <br />Permit Application <br />State Transaction Number <br />Sta�� <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate goverrunental unit <br />is required prior to obtaining a sanitary permit, Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <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)(m), Stats. <br />t <br />k%�Y SGt nd Ll� s�r� S <br />i N7 <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />�GLttn f!7� <br />Parcel # S. �S off- iS b dr <br />O7�Ol�"�i� <br />Or e4 - <br />_ o/boo© <br />Property Owner's Mailing Address <br />Property Location <br />/ of 47'I 193rd Gp? Alw <br />Govt. Lot <br />/,/., Section <br />City, State <br />Zip Code <br />Phone Number <br />/ /?wt&- r /'y� /1/ -s.� <br />3 3 O <br />GS/ -air s:- f 9g� <br />rcle onyyx�--�� <br />T N; R ,� e on; Ji <br />II. Type of Building (check all that apply) <br />Lot # <br />21 or 2 Family Dwelling —Number of Bedrooms <br />Subdivision Name <br />SLA/,_CJtf" <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑State Owned -Describe Use <br />❑ Village of <br />CSM Number <br />T- of <br />XI <br />II1. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A'X <br />New System y <br />❑ Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑Other Modification to Existing System (explain) <br />B. <br />El Permit Renewal <br />❑Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS S stem/Com onent(Device: (Check all that appi <br />❑ Non -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) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (st) System <br />Elevation <br />I <br />VI. Tank Info <br />Capacity in <br />Total # of <br />Manufacturer <br />Gallons <br />Gallons Units <br />w <br />o D <br />o <br />New Tanks <br />Existing Tanks <br />c <br />2 <br />c» <br />U cn <br />rn u V <br />n. <br />Septic or Holding Tank <br />d -I'v 01-V,' <br />O� O / <br />t4i t e f ir <br />Dosing Chamber <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the at plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MFRS Number <br />Business Phone Number <br />Plumber's Address (Street, City, State, Zip Code) <br />76 o _3s rev c ys;4 -- s`Yy53 <br />Coun /De artment Use Only <br />'IKApproved <br />❑ Disapproved <br />Penni <br />$ <br />Date Issued <br />Issu g Agent Si atur <br />❑Owner Given Reason for Denial <br />IX. Conditions of Approval/Reasons for Disapproval <br />r4 � �- L cr.�: v s e;ECEOVE <br />2017 <br />Attacn to compiere pians for ute system ana summit to the County only on paper not less than S 1/2 x ll inches it rzA1 , —J <br />BURNETT COUNTY <br />SBD -6398 (R0313) ZONING <br />