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oY'R7a,tJ County <br /> Industry Services Division <br /> ` 1400 E Washington Ave <br /> �+� i=1 Sanitary Permit Number(to be filled in by Co.) <br /> ` '$ P.O.Box 7162 <br /> Madison,Wl 53707-7162 � N`'2� <br /> .y�,;..-- --Y•- <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 permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Address(if differen than mailing address) <br /> purposesin accordance with the Privacy Law,s.1.5. I m Stars. M G „I <br /> I. Application Information-Please Print All Information 454600'vl 10�W <br /> erty Owner's Name Parcel# /-7 10 "01 (C <br /> r ' a B40, ✓Ck' ey 0?JET-Z -L- 0-11+12-5 e <br /> Property Owner's Mailiin-grAddress /� Property Location <br /> f `�'(J O Govt Lot (/' <br /> City,State /� Zip Code Phone Number i/�,,S ''%,, Section cttc i <br /> �" L102 .7 "7 V T1111 N R 1 Eo <br /> (A Type of Building(check all that apply) Lot# _l►V <br /> 1 or 2 Family Dwelling-Number of Bedrooms Gi Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑State Owned-Describe Use ❑City of <br /> CSM Number ❑Village of <br /> ✓` (� Town of O <br /> Tt <br /> IIL Type of Permit: Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S stem/Com nent/Device: Check all that apply) <br /> 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 /> Desiq <br /> lory(gpd) Resign Soil App cater Dispersal�Ar�a RTC <br /> d(sf) Dis Ar Proposed <br /> I �`�gpd)1I �(/ ((//r+11""s "!lJJ�/ penal po (sfl System Elevation <br /> R � C <br /> VI.Tank Info Capacity in <br /> Gallons Total #of c <br /> Gallons units11TT--__�� Manufacturer <br /> 1�Tanks <br /> "'g Taoks cC U QO ro w C7 a <br /> Septic or Holding Tank <br /> Dosing Chamber If�0 E0] <br /> VII.Responsibility Statement-I,the undersigned,assume resgonsibility for installation oft POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's S' a �/ MP/MPRS Number Business Phone Number <br /> Pat Kissack 881072 715-520-2335 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W7003 Rpppy Lake Rd.,Trego WI 54888 <br /> VIII.Coon (De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued i t Sign <br /> ❑Owner Given Reason for Denial $ 37J ".J-'ZI <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> rcD <br /> c odss <br /> n1 1111 7 8 17171 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inc i I <br /> e <br /> SBD-6398(R03/14) Burnett County <br /> Land Services Department <br />