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cnatar�yr County <br /> r1n <br /> °� Safety and Buildings Division <br /> W <br /> S. <br /> � 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> / <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15. 1)(m),Stats. n�j / C��� / <br /> L Application Information-Please Print All Information �l/ �s�//' 4-All' <br /> Property Owner's Name Parcel# C7 d 3 j, a l5// <br /> L,JrOce Or $ /-'5- © 019,009 <br /> Property Owner's Mailing Address Property Location <br /> 1.365' &jh1'5&r n' Govt.Lot <br /> City,State Zip Code Phone Number %, 1/., Section 3 <br /> f ,, r���!j �,!'/ �/ �/Q (circle one <br /> / J1/ 7 / o` 7 o T��N; R��_E <br /> H.Type of Building(check all that apply) Lot# <br /> Pt or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# !j <br /> ❑Public/Commercial-Describe Use — <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of —C <br /> ._- �Town of ✓ ��s.s <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A" ❑New System 1X-Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> P�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/Treat ent Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsfl Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a <br /> °o$ 2 <br /> �j U d L N + <br /> New Tanks Existing Tanks L c y; 0 <br /> O.U of) ti vi <br /> Septic-4*1� <br /> Dosmg Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign V/WRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent <br /> A)genttt Si <br /> ❑Owner Given Reason for Denial $�� 'y.1 /N• /Y 1 <br /> IX.Conditions of Approval/ReAPPasons for DisapprovalROVED R,.�x <br /> ECEPVE <br /> JUN032019 <br /> Attach to complete plans fo a system and submi ounty only on paper not less thaninches in size <br /> BURNETT COUNTY <br /> ZONING <br /> d,_14 <br />