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Industry Services Division County <br /> 1400 E Washington Ave <br /> Sp ;_` P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI 53701 7162 <br /> UM <br /> Sanitary Permit Application State Transaction Num er <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 forts 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(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 33 t 1 A <br /> Isif-iri u V 4Pnl o7-�Z�z-�/ �y-ZG--�vS�vl-o►g�r� 1 <br /> Property Owner's Mailing Address Property Location <br /> syd�D yqo�h�t City,State Zip Code Phone Number Govt.Lot, , <br /> /�, /+, Section 7- _ <br /> r"l�C 1` 4�v WN �59� /�,, circle one, <br /> II.Type of Building T_1 C) N; R E o J <br /> yp g(check all that apply) Lot# <br /> 1 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 /> 19 Town of SCpff <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. IF New System Y ❑Replacement System ❑Treatment/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 /> S ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> r 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 Application Rate(gpdsf) I Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> a <br /> New Tanks Existing Tanks <br /> c`.U in o, rn is. C7 a <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) Plumber's Sig �� rX:;7Z)-277 <br /> Business Phonc Number <br /> T 114 � <br /> ��S s�-ozo-� <br /> Plumber's Address(Street,City.State,Zip Code) <br /> G 8l Avo w t l-- 4/ t Jeb-p,/c.- W 1. 5''b9 <br /> VIII.Coun /De artment Use Onl <br /> ❑Approved ❑Disapproved Permit Fee p Date Issued g t Si lure <br /> ❑Owner Given Reason for Denial S v�v �ol 81 a <br /> IX.Conditions of Approval/Reasons for Disapproval ov <br /> CECF0M ( <br /> Attach to complete plans for the system and submit to the Counts•only on paper not less than 912 x i 1 5 in size <br /> OCT 5 2021 <br /> SBD-6398(R.08/14) <br /> Burnett County <br /> Land Services Department <br />