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,r''-�'--- Industry Services Division County A <br /> 4... ® 1400 E Washington Ave voi <br /> t :. S I . P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> VA, S -` Madison,WI53707 7162 Sh ,ab 31164 d 6 55 <br /> \h'y'. a4. <br /> ,3_•, c..6.-t-- t- a53 <br /> State Transaction Number <br /> Sanitary Permit Application <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 0f different thyin mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary 2.5 0q 5 (.11e., 6, <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name / Parcel# 34$4 <br /> Zoea41 e 07e11G•1•441/-32 011-04.611ad <br /> Property Owner's Mailing Addressl-f � ) Property Location <br /> 4."06 fat" ]/I`� "" Govt.Lot <br /> City,State Zip Code Phone Number y,, 14, Section -53 <br /> g,r/Q 4 LA); 000 rcle one <br /> II.Type of Building( eek all that apply) Lot g <br /> T 3 I N; R I E o 1�+ <br /> r;iri or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> 446,0t "Wy,_ / <br /> Town of 1,jJq 7 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> wit New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 8. 0 Permit Renewal 0 Permit Revision 0 Chana of PlumberList Previous Permit Number and Date Issued <br /> g 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> WI Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DispersaUTreatment Area Information: <br /> Design Flow <br /> //(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ISV <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units � e <br /> o <br /> =Ncw Tanks Existing Tanks .G U <br /> H <br /> C d E L d 2 <br /> �(��/' /�y��� ��y V.o 'rZ K rn is.t7 a <br /> Septic or Holding Tank ei'__v Z ! ' 5I^4 w 7' <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu is Name(Print) Plum gnaturc MP/MPRS Number Business Ph a Number <br /> . T1�4 � T� f5/95 7/r-s -o <br /> Plumber s Address(Street,City,State,Zip Code) <br /> �z <br /> 668/ A, /,-,4 4 11 4/ (veb71.e.- ("A- 51/69 3 <br /> VIII.County/Department Use Only <br /> Permit Fe VO Date Issued in, f <br /> Approved ❑Disapproved s1-1 <br /> 7•g Sign›,-",,, �- <br /> 0 �la-b II ) l I al ' <br /> ❑Owner Given Reason for Denial f� • ,,�j��� <br /> IX.Conditions of ApprovaUReasons for Disapproval /ice <br /> - D ECIEOWE '-;11 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 812 s II inches n s' h C T 1 ^ 2 021 T <br /> 2.9 <br /> .. U I 3 <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br /> 4_14- - ‘2\4' .... <br /> .ii Li25°` <br />