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Co <br /> > :<,. ' 'r4 Industry Services Division K*„�* <br /> �' 1400 E Washin ton Ave <br /> 9 Sanitary Permit Number(to be tilled in by C .) <br /> P.O. Box7162 6406 <br /> Madison, WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> fn 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 e�1�� ��, 2(p <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. J'1 <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 1A A ri S �i'tS�t'^ Z..�6ga1 t-t�ao`D�QOp <br /> Property Owner's Nlailling Address Property Location <br /> -5-1d 910 �`J�,�ti Aves' Govt.Lot <br /> City,State Zip Code Phone Number %, y,, Section p( rJ <br /> mis Aw trcleone) <br /> II.Type of Building(check all that apply) Lot# T y� N; P /J E ore <br /> Q1 I 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 }l 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 N[oditication 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 /> ❑ <br /> Before Expiration Owner <br /> IV-Iyte,o POWTS..S stem/Corn onent/Device: (Check all that apply) <br /> ( -�lon i'rerized in-Ground ❑Pressurized In-Ground ❑ At-'Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ €faidTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> W.11),is a sa1/Treatment Area Information: <br /> Des igfi, li ili(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o <br /> New Tanks Existing Tanks ❑ <br /> o v <br /> rt U cn in w C7 a <br /> Septic or Hold ng Tank I s- <br /> Dosing Chamber_ <br /> V11.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street City,State,Zip Code) <br /> )77*i0 Aw_, 33' fir/ 1frr L� ,�f8 �3 <br /> VII gun !De artment Use Only <br /> Approved ❑ Disapproved PermiittfFeee; Date Issued / Issuing ge Signa _ <br /> ❑ Owner Given Reason for Denial $ J/ v tr(�'s/ <br /> IX.Conditions of AQQ ova]/Reasons for Disapproval <br /> Aa► �co�&.\ V�S�r (one►4.0AU� OSe, *-930: <br /> corAb,t.e, \tr' I CSM \J.2 ?77 L,oi y csA1 V.Z 9.76 D $ 05OZ60 <br /> ;nAo a s►11 le, \0-'- 3 75 <br /> n1 <br /> jcv- <br /> OCT 2 1 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 s 11 laThe i1h sl <br /> Burnett County <br /> SBD-6398(110313) Land Services Department <br />