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.OirmNrt.A. . County <br /> Industry Services Division X44 <br /> $ IK.; 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> `� P S P.O. Box 7162 ts� ,� <br /> Madison,WI 53707-7162 �� <br /> '44:,:-.„„,..;.:-, .2 -43k3/ 2-5 <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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. I5.04(1)(m),Stats. ^ 8 9cr:Tci /f �QOy/ 6-e r <br /> L Application Information—Please Print All Information �( x‘&if <br /> Property Owner's Name Parcel# fly--5-3=Ve�771 O" <br /> P071c.. Oa fa 446t;ev- a7o1zz�015iIS/Siz: <br /> Property Owner's Mailing Address j Property Location <br /> rol/ <br /> /37 o u e i-r-y ))e Li� Govt.Lot <br /> Cif,State „ ) Zip Code Phone Number 'n 1 ,51./1, Section 1 I � <br /> 1 d 6>7 l�/ �(s, 7 -339C-7/...s-79'/ T"E—'/<110 N R lS(C1E oe(/ <br /> II.Type of Building(check all that apply) Lot# <br /> (� 1 or 2 Family Dwelling—Number of Bedrooms 3 -71 Subdivision Name �9y <br /> ElPublic/Commercial—Describe Use Block# Ta 11 A- ”0077 &told to of a - <br /> 0 City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> 1,31 Town of`J'�Q�.A.• <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. -KNew System 0 Replacement System 0 Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision ❑Change of 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> IA 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 /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Design Soil Application DispersereaR�ired(st) Dispersal Area Proposed(sf) System Elevation <br /> Rate(gpdsf) ``//���! 66 9 96 U/, <br /> VI.Tank Info Capacity in <br /> 2 c <br /> Gallons Total #of <br /> Manufacturer i /3 U y <br /> Gallons Units ` o u 2 ° . l <br /> New Tanks Existing Tanks / a. U -cn N i. e a. <br /> Septic or Holding Tank J D0/j .� ) 1 W 1 e e� d 0 0 ❑ 0 <br /> Dosing Chamber ���/// 0 0 0 0 0 <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'sMP/MPRS Number Business Phone Number <br /> Pat Kissack � 881072 715-520-2335 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W7003 Rappy Lake Rd.,Trego WI 54888 <br /> VIII.County/Department Use Only <br /> 1 Approved ❑ Disapproved Permit Fee Date Issued <br /> Ise..44,4„,....Lt_____ <br /> st}ing Age ignature <br /> 0 Owner Given Reason for Denial $ 37j-7-- //•/J' ex tr. 1 o5 3,( s-11 <br /> IX.Conditions of Approval/Reasons for Disapproval ^ E`�B <br /> VIE <br /> rr;y 1 6 2029 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 z 11 i teres size <br /> Burnett County <br /> SBD-6398(R03/14) Land Services Department <br />