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-7 3U6 JC+CK 6PC04 /ZD d uJ ST y `E i3 <br />IL Coun /De riment Use ---- <br />Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent <br />s 37J - po <br />❑Owner Given Reason for Denial <br />I Conditions of ApprovaUReasons for Disapproval <br />to eompkte plan Cor the system rind s°emit to the Conor <br />7 ody oo paper not kis twin 8 vi s <br />SBD -6398 (R 08/14) <br />OCT 3 0 2017 <br />BURNETT COUNTY <br />ZONING <br />ON COMPUTEPUSCANNE® <br />;.ITyrf�' <br />Industry Services Division <br />Cotnrty <br />l � s �'• <br />14001- Washington Ave <br />� <br />J <br />_ <br />PP <br />a` <br />.O. Box 7162 <br />Madison, Wt 53707-7162 <br />�"'t� Permit Number (to be filled in by Co_) <br />/ -•� <br />Sanitary Permit Application <br />State Transaction Idumber <br />In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />is required prior to obtain' a rani <br />g Lary permit Note: Application forms <br />nn <br />•TT <br />for state-owned POWTS are submitted to <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />purposes in accordance <br />Project Address (if different than mailing address) <br />with the Priv Law, s. 15. I m Stats. <br />I. Application Information _ Please Print All Inf <br />ormation <br />/x/00 I NC*C%ff Sf �GfG� I�RI�� <br />Property Owner's Name <br />L r•,ul c F- <br />Parcel # <br />Propetty OwncesMailingAddress <br />01-l'�{z-z-3�-��_27—s /3-3s4 <br />7 MAD 150-0 0-0 <br />CZ <br />- -perty &Nmlon <br />City, State <br />Zi Code <br />Phone Number <br />Govt Lot _ <br />Val <br />�� <br />C <br />J � 990'/., <br />Section Z7 <br />IL Type of Bnildi rtg(tieclt all that apply) <br />I.ot # <br />T 3 (circle one] <br />N; R �`S" E <br />lor2Family Dwelling - Number ofBedrooms <br />Subdivision Name <br />C1PubliclCotri mercial - Describe Use _ <br />Block # f <br />�1 ti5 l S L <br />❑State Or;eted -Describe Use: <br />CSM Number <br />❑ City of <br />❑ Village of <br />9Townof I�(%gpQ R111�% <br />I[L Type of Permit: (Check only one box on line A Complete tine B if applicable) <br />A <br />New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement <br />only <br />11 Other Modification to Existing System (explain) <br />B <br />Permit Rereevwal <br />Before Expiration <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ permit Transfer to New <br />I ist Previous Permit Number and Date Issued <br />Owner <br />IV. T of POWZ S S Com nent/Deviee: Check all that apply) <br />Non -Pressurised <br />in Ground ❑ Pressurized In -Ground ❑ At -Grade Mound > 24 in. of suitable soil ❑ Maprd < 24 in. of suitable soil <br />❑ Holding Tank 11 Other Dispersal Component (explain) <br />V. Dis rsaVTreatmeot Area Information; Pretreatment Device <br />(explain) <br />Design Flow (Bpd) Design Soil Application Rate(gpdsf) <br />Ixspersal <br />jr: Area Required (sf) Dispersal Area Proposed (si) System <br />VI. Tank Info <br />Capacity m <br />Elevation <br />Gallons <br />Total # of Manufacturer <br />Gallons Units a <br />New Tanks Existing Tic <br />o 'Q <br />uR. v U <br />Septic � <br />° U h H rn w C7 a <br />Dosing Chamber <br />Sp p <br />C <br />Ga ba <br />VII. Responsibility Statement- i, the undersigned, assume rYs ° bitty for insta[latioa of the POWTS shaven <br />Plumber's Name (Print) the <br />=be�l5igrr� <br />on attached <br />MR111111C, <br />plass <br />Business Phone Number <br />ty <br />Plumber's Address (Sheet City, State, Zip Code) <br />�_^ <br />'T ('Num<ber <br />-7 3U6 JC+CK 6PC04 /ZD d uJ ST y `E i3 <br />IL Coun /De riment Use ---- <br />Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent <br />s 37J - po <br />❑Owner Given Reason for Denial <br />I Conditions of ApprovaUReasons for Disapproval <br />to eompkte plan Cor the system rind s°emit to the Conor <br />7 ody oo paper not kis twin 8 vi s <br />SBD -6398 (R 08/14) <br />OCT 3 0 2017 <br />BURNETT COUNTY <br />ZONING <br />