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/ ;ITi`•c'r;--..` County <br /> -- <br /> 4::.-?;' ,, ,. --0;, Industry Services Division i3 u b'n ei <br /> i�. 1 :.. ,- ;, 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be tilled in by Co.) <br /> V'' ` Pi P.O. Box 7162 SA-J_,21�o2. <br /> ,.�: t,'.. :::- ;s, Madison, WI 53707-7162 <br /> ‘-11.i>,-.- -":"0 ,-3,C./r7 <br /> Sanitary Permit Application State Transaction Number <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 pennit. Note:Application fonns 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-33.16 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. RolI. Application Information-Please Print All Information wooer' Greek. <br /> Property Owner's Name L, Parcel# 3 g_17_23-3-ad-b0 0 <br /> Property Owner's Mailing Address Property Location <br /> p0 aoX 06' <br /> Govt.Lot <br /> City,State Zip Code Phone Number / /a, Section d.3 <br /> 1/rco In/3- s9 g-1€ cmcleone <br /> H.Type of Building(check all that apply) Lot# T 3 g N; R /� E or <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> 0 Public/Commercial-Describe Use ❑ City of • <br /> CSM Number El Village of <br /> ❑State Owned-Describe Use <br /> VTown of Z?t hi Cif <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> x New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision <br /> ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.:Cype of POWTS System/Component/Device: (Check all that apply) <br /> Non PieSSllIlzed In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑,Hgldm=Tank 0 Other Dispersal Component(explain) 0 Pretreahnent Device(explain) <br /> V:-Dispersal/Treatment Area Information: ` <br /> Desig Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 , s Goo_ ovoa RB. a <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units a, o - u <br /> New Tanks Existing Tanks o 0 T <br /> n,U C.7) ti v, u.C7 a <br /> Septic or Holding Tank 510 <br /> 890 <br /> p ,o <br /> Dosing Chamber-. Sao .5-0I ��/L�` ` i 3, <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature IVIP/MPRS Number Business Phone Number <br /> gl G/L /7i0 ,4111 vt S R-i... "..6 {V dl 8S/ 743- /ss`7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1776 0 %' y 3f w-e,6371e 05--- j-'4/5'93 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued Issuing Agent/Ste°V( lure <br /> Npproved 0 Disapproved <br /> 375 '7•21,. • 2/ .G -1 <br /> ❑ Owner Given Reason for Denial •A _, <br /> IX.Conditions of Approval/Reasons for Disapproval _ 1 - _ECEO ! <br /> DWEI1 <br /> ii, APR 2 0 2021 _ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 a 1 .chrs size <br /> �, Burnett County <br /> £ i,.t. Land Services Department <br /> SBD-6398(R0313) <br />