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� 1 County <br /> / � Industry Services Division R,,. g�f <br /> a; DS I.. 1400 E Washington Ave <br /> Sanitary Pgrmit Number(to tilled in by Co.) <br /> P$ i;; P.O.Box 7162 �✓�d/— IS- 2�/ <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State rsactionNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit c,*,6 y ;C vl C'rJ <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 Servies. Personal information you provide may be used for secondary d�7G/ <br /> purposes in accordance with the PrivacyLaw,s. 15.04(1)(m),Stats. J <br /> I. Application Information-Please Print All Information m/n e v✓a /PGr <br /> Property Owner's Name Parcel# <br /> 1 trra -od-3-til-ib•39-9 <br /> /uM D--ewlskv, <br /> -COO- o//Dop <br /> Property Owner's Mailing Address Property Location <br /> 173/`7 P4 ✓el11.4- 0 Govt.Lot <br /> City,State Zip Code Phone Number /VW y,, -10 y,. Section 3"V <br /> &oftr Pre.lrie MAI -57�3NbeN; R /,o(circE ol)le one) <br /> / <br /> [I.Type of Building(check all that apply) Lot# T L/ <br /> Z1 I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of Slti/JS <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' New S <br /> y stem <br /> ❑ 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 /> E4 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) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 74 1 . ' 4?,.j9 113a I C?7.. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units _ <br /> c <br /> New Tanks Existing Tanks y L y H J <br /> ` y m <br /> 0 <br /> n.t.J vt H rn v. V a <br /> Septic or Holding Tank 75.0 <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> 715= 8(c�—t�16-7 <br /> Plumber's Address Street,City,State,Zip Code) <br /> � 77 Q �•-- • S Lv-e dJt.,� ltJ� Sy8'�3 <br /> VIIL County/Department Use Only <br /> (Approved ❑ Disapproved Permit Feer Date Issued Issuing A 1gnaNre <br /> ❑ Owner Given Reason for Denial $ V 4 1&A IG ,ar , <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> EcoVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches i s <br /> APR S 2015 9 <br /> SBD-6398(R0313) BURNETT COUNTY <br /> ZONING <br />