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nuucu w cuu,piete pians tar me system aria suomtt to cue county only on paper not less thanWtG x W inches in size <br />BURNETT COUNTY <br />ZONING <br />SBD -6398 (R0313) <br />Industry Services Division <br />County <br />OLA ✓'y Oct 225"5` q <br />s�. ( <br />E Washington ashin ton Ave <br />9 <br />P.O. Box 7162 <br />Sanitary Permit Number (to be tilled in by Co.) <br />/ <br />Madison, WI 53707-7162 <br />-'r.1i,4Ys <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />Project-Pcddress (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 />Gp44.A;t v <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />299S'S Ct-'Le4en L <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />tIi S tov+�eI>qq-oli4600 <br />07-43a--yl-/(o-3S-S <br />Property Owner's Mailing Address <br />Property Location <br />?# 3ck 33) <br />Govt. Lot <br />y,, 14, Section 3f <br />City, State <br />Zip Code <br />Phone Number <br />(JG. to 6 G r tvS� <br />03 0 <br />(circle one) <br />T y� N; R / E or <br />II. Type of Building (check all that apply) <br />Lot # <br />I or 2 Family Dwelling —Number of Bedrooms <br />Subdivision Name <br />I. <br />Block # <br />❑ Public/Commercial —Describe Use <br />❑ City of <br />❑State Owned —Describe Use <br />❑ Village of <br />CSM Number <br />Town of <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System y <br />[I Replacement System <br />� Treatment/Holding Tank Replacement Only <br />El Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />EJ 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 apply) <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 d) <br />Design Soil Application RateO <br />Dispersal Area Required (so <br />Dispersal Area Proposed (st) <br />System Elevation <br />VI. Tank Info <br />Capacity in Total # of <br />Manufacturer <br />Gallons Gallons Units <br />� v <br />C, <br />U <br />N <br />New Tanks Existing Tanks <br />L 0 <br />a U <br />Cn <br />u <br />C.0 <br />G. <br />Septic or Holding Tank <br />7 f--6 <br />7s'0 <br />Dosing Chamber <br />StJ 0 <br />,S'i'd <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POINTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature , f <br />MP/MPRS Number <br />Business Phone Number <br />:86(x- 4f15� <br />/� rG a kt n S <br />�cj%L �/ <br />dalv�B•S`/ <br />7/S <br />Plumber's Address (Street, City, State, Zip Code) <br />017,? , .t s5 7 3 <br />VIII.County/De artment Use Onl <br />APermit <br />Approved <br />❑ Disapproved <br />Fee <br />ssO <br />Date Issued <br />IssuingAgent Si atur <br />g � <br />❑ Owner Given Reason for Denial <br />�1 <br />sap` l� <br />� X&_ <br />/ s for Disapproval lig "14 � � V E <br />IY. CApflu <br />D <br />,n MAY 15 2018 <br />nuucu w cuu,piete pians tar me system aria suomtt to cue county only on paper not less thanWtG x W inches in size <br />BURNETT COUNTY <br />ZONING <br />SBD -6398 (R0313) <br />