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County Industry Services Division <br /> ~\' 1400 E Washington Ave <br /> Isl SrP.O.Box 7162 <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled n y Co.) <br /> �tl BAN-2c—fib/ �3 (9 <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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary 'purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats, w„�O� <br /> I. Application Information—Please Print All Information `�i <br /> Property Owner's Name Parcel# <br /> hex) Zc�& ��-oezo-z rc- yr-s �s-`�o-o�►000 <br /> Property Owner's Mailing Address Property Location <br /> qZ18 OUAMOUW4-v Govt.Lot <br /> City,State Zip Code Phone Number y, Ya, Section <br /> fi A 19677�? role one <br /> T�_N; R Eo&/ <br /> II.Type of uilding(check all that apply) Lot# <br /> I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Town of_1A <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. <br /> ❑New System ❑ Replacement System ryTreatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer to New <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 ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil(pp anon Rate(gpdsf) Dispersal t�re��equired(sf) Dispersal AreaJProposed(sf) System��ation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ' c <br /> New Tanks Existing Tanks <br /> ` p y r1 <br /> a U in y rn Lt.. C7 a <br /> Seine or Holding Tank ' ` r <br /> Dosing Chamber iI^ �.J <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P is 7Name(Print) Plumber's Si atu MP/MPRS Number Business Phone Number <br /> lu <br /> 4J /���i 0*5195z/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �I Avo Aw IA W/ kJebrv,/cr c„ , 5y09 <br /> VIII.County/ e artment Use Only <br /> ❑Approved ❑Disapproved Permit Feee (Date Issued/�t u Ag t Signa <br /> ❑Owner Given Reason for Denial $ 3 Z el mot/�/ ` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 'Con`c- m�s't meek a�� s�C�oo.ck,s. 2S% worn weU <br /> p;s�ec'Sa� .o- s4ra��c� Id% fnrom <br /> ace �'t�t✓c` a M <br /> `l ei LA I C1 2ft <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 inn 11 i size <br /> A G 2 6 2621 <br /> I LU <br /> SBD-6398(R.08114) Burnett County <br /> Land Services Department <br />