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r„,............ County,;z , ,�• Et <br /> Safety and Buildings Division 1 3l�k�i if201 W.Washington Ave.,P.O.Box 7162 Sanitaty <br /> ° a p# ,® Madison,WI 53707-71621 i 'er(to be filled in by Co. <br /> \tts--• T <br /> 4 3/ gslc,5ra- la <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.2I(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �'1S 12 Int%�� 'L' <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different i mailing adds <br /> """4 purposes <br /> Department of.Safety and Professional Servies. Personal information you provide may be used for secondary Z 57.5/ / d <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. �D• C- <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 0.1-6,Z-1-1-,i -15- 2 <br /> hEDR -( C At t+ .l u I i L_ _LLA ie_ Cii-Vi\'t)6,,e0ah i - eCO -o 1 ZDww) 5,y <br /> Property Owner's Mailing Address <br /> 'l.) Property Location <br /> V J, �VE�3 L i E 1L) W i z Govt Lot <br /> City,State Zip Codeyy�� Phone Number 1� ��� jv '/, Section z t <br /> lJis,t,) )&I \A i s 9[.t,_ () T IU N� R , (circle one', <br /> II.Type of Building(check all that apply) Lot# E er <br /> ❑I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> )11)ublic/Commercial-Describe Use ,f- t'‘.& W1IJ 1\ <br /> 0 City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of yy <br /> ,Town of --1'�i.-\ N <br /> III.TVs of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' %New System ys 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(exp <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration <br /> Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: I DCJ CLI t"IC U 0_Fl t,,V?..IZS <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Re ui,ed(sf) Dispersal Area Proposed(sf) System Elevation YS , <br /> ZcCii 9 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a t.d <br /> New Tanks Existing Tanks E U w a <br /> r E <br /> Septic or Holding Tank 3() CC; I VVI r..5 Ei� X <br /> n,/) �t.. .�..' <br /> Dosing Chamber /Ci COO j vv"I FS iZ j- <br /> VII.Responsibility Statement-I,the undersigned,assume responsibili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) is gnatu <br /> it rf/ /MFRS fiber Business Phone Number <br /> - 1= X `i G 7 Z221Z, 7I5-9c1I-3i.t56 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Pt, 130 x 51,s , ris w I gliti6q <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> I�.Approved 0 Disapproved <br /> 0 Owner Given Reason for Denial $ -3-7 S -.5.--24 LJ. L <br /> IX.Conditions of Approval/Reasons for Disapproval tlEcEoyso <br /> MAR 022021 <br /> Attach to complete plans for the system and submit to the County only on paper not less din 8r a 11 inches In size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) <br /> 1 2� <br />