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N. <br /> .r'w ,x.-,r?r. Coun <br /> '4 8 <br /> 7=. 'r '''':`\ IndustryServices Division tti rr-,elf" <br /> i f= o A. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> s``� PS/ P.O. Box 7162Sill-KJ „`5� / <br /> '4�. 4, Madison, WI 53707-7162 `7 <br /> 8;;� > C -12D — /37 <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 (o23 r7 I I <br /> isrequired 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 <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. al 9 4„,,/e-eS dr <br /> I. Application Information-Please Print All Information ft 21448 <br /> Property Owner's Name Parcel# <br /> ` e GcfrlVe fur,ity d6 G4./ec Ltd. a7 vet-�l-�/_Ss000 as-aoS <br /> Property Owner's Mailing Address Property Location <br /> /y y d$ /I//Zed B.d Tel Govt.Lot <br /> City,State Zip Code Phone Number y, '4, Section A6 <br /> RI"41..q ,,,44" /Yl...r /9 /0 7 (circle one <br /> T el/ N; R ,IS- E of <br /> II.Type of Building(check all that apply) Lot# <br /> 1 or2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number El Village of <br /> ❑State Owned-Describe Use f Gv'1f-f <br /> 2'Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. pil New System y 0 Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑ Change of Plumber <br /> ❑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 /> E Nor Pressurized In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑4-fgldtn7Tank 0 Other Dispersal Component(explain) ❑Pretreahnent Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispe :: w re: -rop. -d(st) System Elevation <br /> Li-70 , 7 6ti3 65-0 7.4.5 0- I) 41 <br /> VI.Tank Info Capacity in Total #of orer <br /> Gallons Gallons Units o Y 3 <br /> New Tanks Existing Tanks t o v 0 <br /> c,U ',7) y cn u.V Q0.. <br /> - <br /> Septic or Holding Tank /0.5-0 /es v / ,�N R/f�a7, r <br /> Dosing Chamber_ i :} <br /> VII.Responsibility Statement- I,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 /> /Z l c IL- /1/4/0k to I /-1,t4-,4?" j' ,1445-8;57 745`-8.0 ` e/Z77 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> )77 ,c/ / -moi/iw'y Z..1 11/4,4 [ . ley . <br /> VIII.County/Department Use Only / <br /> pproved ❑ Disapproved Permit7Fee Date ssue. suing Ar nt Siv atu- / <br /> vvvvv <br /> 0 Owner Given Reason for Denial $ �+�S s <br /> OO 4 7 ZDZo , <br /> r V V t <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> A t>ro vtFi't fa WU,ts4- k 50.4- fro'v. Well. sr <br /> 013 b Aceks of 22 Row rev.,it,/ {or �lispersa.Q area,, - I JUL 2 3 2020 <br /> 41 be. " Soft co . OHt41141. L LI ,--J <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches rsize-- - - ---- — <br /> Burnett County <br /> . Department V. Land Services <br /> SBD-6393(80313) ry (��5t'3 ItL � <br />