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Attach to complete plans for the system and submit to the County only on paper not less than 8 t/V l t i hes i s V LU) <br />BURNETT COUNTY <br />SBD-6393 (R0313) ZONING <br />Industry Services Division <br />County^7 <br />✓1-ely <br />'Ave <br />'D, <br />ton <br />1400 E Washington <br />g <br />P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />` <br />yi .� <br />d <br />5 l ` r <br />Madison, VVI 53707-7162 <br />U o 'a q <br />�'ratKa� <br />Sanitary Permit Application <br />State Transaction Number <br />111an <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project Address (if different than mailing address) <br />is required prior to obtaining a sanitary pen -nit. 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 />�� K <br />purposes in accordance with the Privacy Law, s. 1 5.04(t)(m), Stats. <br />Q r S� <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel #0 %%_ I GI S IS-- 3 4 0 <br />Oy70&O <br />Property Owner's Mailing Address <br />Property Location <br />'s <br />> d LT! -k ! n C N t/ e <br />Govt. Lot <br />y,, /,, Section 1 g <br />City, State <br />Zip Code Phone <br />Number <br />/✓ <br />df.� <br />o <br />�/ Jo <br />(circle one <br />(YO <br />T N; R �� E off <br />11. Type of Building (check all that apply) Lot <br /># <br />Subdivision Name-lewsetvS `al(t 5 -It <br />/ <br />I or 2 Family Dwelling - Number of Bedrooms lJ �` �^ °` '` <br />¢ <br />Block <br />��LLOW Ga C, <br /># <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ CSM <br />Owned -Describe Use <br />11 Village ofState // <br />KTownof aLt1 <br />Number <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />A -New System <br />Replacement System <br />❑ Treatment/Holdng Tank Replacement Only <br />Other Modification to Existing System (explain) <br />B. <br />ElPermit Renewal <br />❑ Pen -nit Revision <br />11Change of Plumber <br />ElPermit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />�A/✓. <br />IV. Type of POWTS Sys tem/Component/Device: (Check all that apply) <br />Non Pressiirized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />d❑ <br />lat Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/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 />3 0 0 <br />-- <br />�— <br />— <br />V1. Tank Info <br />Capacity in Total <br /># of <br />Manufacturer <br />Gallons Gallons <br />Units <br />o <br />U <br />o <br />c U <br />n <br />Y <br />rn <br />c C7 a <br />New Tanks <br />Existing Tanks <br />Septic or Holding Tank <br />d B d <br />�( 060 <br />I,/ % ,e Se <br />Dosing Chamber <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 Signature <br />NIP/MPRS Number <br />Business Phone Number <br />Plumber's Address (Street, City, State,, Zip Code) <br />>� <br />760 / /, 3 s 1,1-P ✓ S � e <br />I1I. County_/De artment tse Only <br />Approved <br />El Disapproved <br />Permit Fez <br />0 0 <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />_ <br />$ 7� 12-11-19 <br />IX. Conditions of Approval/Reasons for Disapproval <br />D �c��o�E <br />APPROVED <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 t/V l t i hes i s V LU) <br />BURNETT COUNTY <br />SBD-6393 (R0313) ZONING <br />