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County-7-, <br /> / +. � J Safety and Buildings Division ta-n <br /> A r 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be tilled in by Co.) <br /> a..s Madison,WI 53707-7162 5A-NI,..a( - .2.41 1 <br /> t _` vi <br /> -.�` C -7-- 2i --L'93 63x70 7 <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 fferent than maili¢g address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary \/,� L uOc II(1/ <br /> purposes in accordance with the Privacy Law,s. 15.04(IXm),Stats. 1 4L-� <br /> I. Application Information-Please Print All Information /`,u q / <br /> Pro 'Owner's me Parcel# 6-1-6/b_Z-3/_l� _zCb,SIS,Z- <br /> ///V) i Ce —rAlc i�1`#'LGIa 7 -zic <br /> Property Owner's Mailing Ad ress Property Location <br /> LJ ?zQc'S / Govt.Lot (� <br /> Crty Sttate ��j� / r Zip Code Phone/ N/umber/Q 7 J y, y., Section ZD <br /> LU�cS�.S(�V 1`t 1 J/ Pet �i3` - -G ,K. T 39 N; R //(circle Eor� <br /> II.Type of Building(check all that'apply) Lot# L(O <br /> Ell or 2 Family Dwelling-Number of Bedrooms 3 1$ Subdivisionauo <br /> ame / ti <br /> Block# C <br /> 0 Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Bi-own of / <br /> III.Type <br /> eof Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. {'J New System ❑Replacement System 0 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 /> ❑Permit Transfer to Ncw <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Njon-Pressurized in-Ground 0 Pressurized In-Ground 0 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 A plication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation i <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> / <br /> u v <br /> Now Tanks Existing Tanks 1 r u an <br /> w U n w ri�(7 0 <br /> Septic or Holding Tank .----• /CC) / j✓ C /1/, <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume re o siblii$y for installation of the POWTS shown on the attached plans. <br /> P mber's Name( nt) PluttyFr's Si r MP/MPRS Number Business Phone Number <br /> (� ° 5.?. <br /> .� 7/c 7/ V9C <br /> Lm 's Address(Strec City,State,Zip Code) <br /> 9 0� /,cJeW� Ci- . � <br /> VIII.County/Department Use Only / <br /> Permit Feed Date Issued in ge *ignatu / <br /> ❑Approved ❑Disapproved $1-15 '- -- <br /> � !7' �/I� ��� � /� / , <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovalReasons for Disapproval / / <br /> D ECIE [IVE, n <br /> Attaeh to complete plans for the system and submit to the County only on paper <br /> er not I than 8 to x I l in•'on in s UG 1 7 2021 <br /> iJ 111 Z i <br /> SBD-6398(R. I1/11) 1 ���� Burnett County <br /> Land Services Department <br />