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Cou <br /> Industry Services Division 9K.r A <br /> 1400 E Washington Ave Sanitary Permit Numberbe tilled in by Co.) <br /> P.O. Box 7162 ( _a <br /> Madison, WI 53707-7162 <br /> -reL374G <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 Servies. Personal information you provide maybe used for secondary 94 <br /> purposes m accordance with the Privacy Law,s.15.04(i)(m),Stats. dC� LK /�O <br /> I. Application Information—Please Print All Information y <br /> Property Owner's Name Parcel# <br /> C/thfmn <br /> Property Owner's Mailing Address Property Location <br /> wA 8 Xr.ni'-k N Govt.Lot <br /> City,State Zip Code Phone Number y, ~ y,, Section 3, <br /> IZe((, .0 0 AA 1circle one <br /> 11.'Type of Building(check all that apply) Lot# p T AR !6 E c�V <br /> 9 1 or Family Dwelling—Number of Bedrooms � p Subdivision Name <br /> B lock# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number p Village of <br /> V.ay 11 aIY3 ®Townof ,Swt<S <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> X New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber I ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T "'e.of POWTS,S stem/Corn ----I ---'-e: (Check all that apply) <br /> �No'n i°e razed hi-Ground ❑ Pressurized ln-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑€{a1dTarik ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> W`D s der-al/Treatment Area Information: <br /> Des b ow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> 3 0 o 1 -7IYA 5 yso 53. o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units -U o <br /> New Tanks ID Existing Tanks o u 0 <br /> c U cn m w V a. <br /> Septic or Holding Tank /G <br /> Dosing Chamber_ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the PObVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Siansture MP/MPRS Number Business Phone Number <br /> /?/G!4 1-10 /G,6.f j?-�-.��• 1� d,�,s 8Sl 7/S Z%61- 41/.3"7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Coun /De artment Use Onl <br /> Approved El Disapproved Permit Fee Date Issued I u' A t$ Signature <br /> O <br /> ❑Owner Given Reason for Denial 3 2S� <br /> 0 Jam'Z� <br /> IX.Conditions of Approval/Reasons for Disapproval 6 <br /> ILak�gCE0MC <br /> n p, <br /> �. <br /> Attach to complete plans for the system and submit to the County only on paper not less than S In x in site <br /> Burnett County <br /> SBD-6398(R0313) Land Services Department <br />