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Industry Services Division County <br /> ;r 1400 E Washington Ave &,qieH <br /> P.O.Box 7162 Sanitary Permit Number to be filled in by Co. <br /> S Madison,WI 53707-7162 <br /> Sanitary Permit Application mbe Stat-IransactionNur <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental trait ,Jf_4- D 7 Z)D/L S Z—L <br /> is required 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 /> purposes in accordance with the Privacy Law,s_ 15.04(i)(m),Stats. 1 y <br /> I. Application Information—Please Print All Information AV ,.q <br /> Property Owner's Name Parcel# f 3/ '3 <br /> dave /VI°ill C� 07 dZO-Z-ham/6-T -5'0EA0,V-04MC <br /> Property Owner's Mailing Address//�� // Property Location <br /> '/Z AltGbU�yr `Al Govt.Lot �^ <br /> City,State Zip Code Phone Number Y,, '/,, Section ? <br /> ow /� rcle ones <br /> ✓"/ T "l O N; R �� E of;fivC <br /> II.Type of Buildin (check all that apply) Lot# <br /> Y1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �New System <br /> y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑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 /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil FMound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersallTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> y66 .o ysa 1140 9�6 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units � U 'OU <br /> New Tanks Existing Tanks <br /> a U in H rn is C7 C. <br /> Septic or Holding Tank 0 <br /> Dosing Chamber 00 <br /> VI1.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(PriUt/ <br /> Plumber's Si a MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> G&I AvoA r4 l A Wol welbr2ler U,- 5y�9 <br /> VIII.County/ e artment Use Only <br /> proved ❑ Disapproved Permit Fee Date Issued Lc in Age •- <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 2137 <br /> 5 E I 9 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I hes in size <br /> JUL 15 2021 <br /> SBD-6398(R.08114) Burnett ounty <br /> Land Services Department <br />