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Industry <br /> In Services Division County <br /> 1400 E Washington Ave uf'hE. <br /> r� = P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI53707-7162 <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 4>4 j - t7,4 Z/D/t//3'e— <br /> is requited 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 Services.Personal information you provide may be used for secondary <br /> urposes in accordance with the Privacy Law,s.15. 1 m,Stats. IISbQ P. <br /> L Application Information—Please Print All Information L, <br /> Property Owner's Name Parcel# -7-3 8•3 a <br /> Ate, �- � a�b �ha(e(`s�� �•e3y-2-37`•!8-tor-! o2-om <br /> Property Owner's Mailing Address Property Location <br /> Aol a Govt.Lot � <br /> Ci State Zip Code Phone Number <br /> /V Vf /,, Alfr /<, Section Z Z <br /> arcircle on <br /> WS <br /> II.Type of Building(check all that apply) ? Lot# T 3 N; R E o <br /> 491 or 2 Family Dwelling-Number of Bedrooms J Subdivision Name <br /> Block# C5-m Va I 6:? <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of -- � <br /> Town of / f�(C <br /> III.Type of Permit- (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New Sy <br /> stem Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Frosting System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S m/Co bMevke: Check all that <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil 91 Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispermsatR reatmcut Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y640 < q6a qsa 1 7C d <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks c ai w a <br /> Septic or Hoklmg Tank ` �1• SE!• K <br /> Dosing Chamber 11 L _ Tzo _ ,k <br /> VH.Responsibility Statement-1,the wmkr3*ned,assame respensW q for installation of the POW YS shown on the attached plans. <br /> Plum N ) Phmm s Si MP/MPRS Number Busigess Phone Number <br /> It <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Coun /Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued �Wtsignor <br /> a p <br /> ❑Owner Given Reason for Denial 3 7� 0 2 <br /> DL Conditions of Approval/Reasons for Disapproval <br /> H C �C � dL <br /> Attach to camplew Pb—for the syseea and submit to the County only an paper not Ie s than 8 in z in Sim <br /> JUL 2 8 2021 <br /> Burnett County <br /> SBD-6398(1L 08/14) Land Services Department <br />