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e r 1 County Indust rY Services Division )tn,Yn-e I� <br /> 's' 1400 E Washington Ave Sanitary Permit Number s •,,;ti ) ry (to be tilled in by Co.) <br /> P.O. Box 7162 / <br /> "� �.� Madison, WI 53707-7162 <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 <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 may be used for secondary 6 SQ Ot <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. !! [ <br /> I. Application Information—Please Print All Information Flo W A <br /> Property Owner's Name Parcel# 3S5' /S 3S 7 <br /> Pro e Owner's Address ZL�37 C"Jd s DDO <br /> p rty g Property Location <br /> 15-95 115.{1-ti /4 u e Govt.Lot <br /> City,State Zip Code Phone Number y, /, Section 3-s" <br /> Ct%N f 1A0 4 bt/= ,�-4 Fok 4f T�[_N R /(circle onr� <br /> 11.Type of Building(check all that apply) Lot# <br /> .r I or 2 Family Dwelling—Number of Bedrooms O� Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> Town of Sw I,SS <br /> II1.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 ❑Pen-nit Revision ❑Change of Piuinber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> mlkoe.of PoWTS.S stem/Con onent/Device: (Check all that apply) <br /> essunzed In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ F{oldip�Taak ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V-Dis.Y.'r al/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> V1.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units o D <br /> New Tanks Existing Tanks P <br /> a, a -2B _6 <br /> Septic or Holding Tank X <br /> Dosing Chamber <br /> i -•r <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' MP/MPRS Number Business Phone Number <br /> J a„S 8.s/ 7/J C//•S� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VI our /De artment Use Only <br /> Approved ❑ Disapproved $ermit Fee Date Issued Issuing Agent Signature <br /> El Owner Given Reason for Denial 37.5 J I/.�- Z/ �- /� v <br /> IX Conditions of Approval/Reasons for Disapproval E � R n E <br /> I <br /> v <br /> J J N 0 3 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size <br /> Burnett County <br /> SBD-6393(R0313) Land Services Department <br />