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1 �: v _ —- induStr;S�rviCL��iv�SUM COM}, A, <br /> 14401*Veashington A.•e ,V <br /> i, t P.O.€o 7162 j Sari ry Permit Number;ti be Illicit in by Co t <br /> 1 \4 disson,ttrl 53707-71 r"s2 1 ( C) 72, ' <br /> San►-�l 33`{ <br /> .— # - State Transaction Number <br /> Sanitary Permit it pplica ion NA <br /> In accordance With SPS 38;2 i, Wis.Adm Code„submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit Note.Application farms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Prof ssional Services.Personal information you provide may be use for secondary <br /> purposes in accordance with the Privacy Lawa.I5.01(l Xm),Stats. CHI 6 NI, Mu L44:5- R . <br /> L Application Information-Please Print All Information _ <br /> Pr'opertyOwnersNam <br /> y Parcel# 07�,,.2.-3B-1�'-5 -� <br /> G-H be .$R -A it os_oar—02700D 2.2.4 <br /> Property Owner's Mailing Address ( Property Location <br /> 7Z6,6- 61-44. ii Goat.Cot_ --- <br /> City,State / Zip axle j Phone Number - +a; - 'h. Section IT <br /> 5 A' 1`�"" -ta7 (circle ortY�-1 <br /> ✓���l J t w�- t�' " ' ? f 3g_ -N: R 11 P,o, ,. <br /> H.Type of Building(cheek all that t;pply) Lot if2- -, <br /> yiI or 2 Family Dwelling-Number of Bedrooms__ l�l Subdivision Name <br /> ///�� NA <br /> - <br /> tN SNE j Block ti <br /> ❑Public/Commercial-De cribe Use______�__ j <br /> 0 CSMNumber'376,S 10V'illageo' -f. - <br /> State Owned-.Duscnbe Us� _ ---- ! <br /> VI-l� �izl �y+Town Di �QS <br /> III.Type of Permit: (Check only one€rai Ott line A. Complete line B if applicable) <br /> A. <br /> New System^. 0 Replacement System 0 TreatmentfHOldittg Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 1 <br /> rntitRencu l 0 Permit RevisionList Previous Permit Number and Date Issued <br /> B. 0 Pe <br /> 0 Change of Plumber 0 Pemtit Transfer to New <br /> . Before Expiration i 1 Owner <br /> IV.Tope of POWTS SystensIComponent/Deviee: ((leek aft(bat apply) <br /> Q Nov-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<74 in.of suitable soil <br /> XHolding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain)___ <br /> ! -- —V.Dispersal/Treatment Area Information: __! <br /> Design Flow(gpd) Design Soil Applieetion Ratc(gpdsf) Dispersal Area Required(sf) I Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capamty in Total #of J Manufacturer ) I l <br /> Gallons Gallons Units 1 s w o 7 I <br /> 421 <br /> n amus New•Tanks Existing'leeks E ' D u 'g Ti 1 is °? <br /> Septic or Holding Tank 1100 I?00 / i WIC f2 >C <br /> Dosing Chamber OOlI��lIJJ O'nn � <br /> � � i . <br /> VII.Responsibility Statement-I,the undersigned,a ren•v. r for iastnliation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum r Sia &3llititlfeWNumber 1 Business Phone Number <br /> C()P Y eI s%::k,' 5:2-' Via/ I 715-;5•G-4,-Sil`dy <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 3cL. -Cf j: eK 1'3.20'1{-12 LA;217 s-11---V, (.4-.---3: 5i?(-Z5 <br /> VIII.County/Deportment Use Only . '. <br /> R-Approved 0 Disapproved Permit Fee — Date Issued I I in ACP 'Sigma ,, <br /> 3 75 111/y/•-I II- f_ <br /> ❑Owner Given Reason for Denial 1 eif�// <br /> LX.Conditions of Approval/Reasons for Disapproval <br /> / <br /> ry..11 4-723 <br /> .ttatea to evmplare plans for the system and submit to the Comity only on paper not frets than 8 12 x 11 tae to in <br /> , _ <br /> C� © ' OVE <br /> 11 Nov 1 21i?1 <br /> f9,� la` <br /> SBD-6395(R.0R/14) - <br /> Burnett County <br /> Land Services Department <br />