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r eInst.. J ices Division County ,- <br /> I I I �+ashington Ave /�e se...-3 , <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,` Madison.WI 53707-7162 SFN _.2-57 <br /> Or si45-- <br /> State TransactionNumber <br /> Sanitary Permit Application <br /> In <br /> 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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# .- 93 9,1 <br /> f 1 <br /> Ar',/.1(2,4e 1 i `lf X e-Vs;t-` -{.. /Gt,'r rn C-oi• 2,-...X- -y'/•3ryre'/-cere-`//1 e3C <br /> Property Owner's Mailing/Address Property Location <br /> J 1./et /L`4:.'• tie. Rd Govt.Lot <br /> City,State / Zip Code 1 Phone Number £C y,, / '/, Section 3/ <br /> /-1 c`"clEi r C.., 64-f -r 51/ M 3 / I /..3f .222-6L r.,(..) T 3.s N, R i `(circle one) <br /> II.Type of Building(check all that apply) Lot# — <br /> 1 or 2 Family Dwelling-Number of Bedrooms one__ Subdivision Name <br /> Block# - <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ®Town of 44.fL'//F t1 C-_ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. � <br /> ❑New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification 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 /> Before Expiration Owner <br /> W.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> 03 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> /512- -- - J <br /> VI.Tank Info Capacity in Total #of Manufacturer ' <br /> Gallons Gallons Units s o�„ v <br /> New Tanks Existing Tanks c y t ro <br /> Lo _ <br /> U EY,. v, ,n ci.. C7 ^ <br /> Septic or Holding Talc x• 1L^Cf: / L:.• t'Sr.,- ✓C <br /> c^ .-,(,.11 t le —I <br /> Dosing Chamber I j <br /> I <br /> —I <br /> VII.Responsibility Statement- I,the undersigned,assume responsibili for installation of the POWTS shown on the attached plans. <br /> P!u s Name/ Plurpbts" Signa MP/MPRS Number Business Phone Number I <br /> /Obe / ^/SO i, /t- �.� i35C, 5 /,' X3,3-�7Sct) <br /> Plumber's Address(Street,City,State,Zip Code) <br /> . -3�/7 . its 'A `s r /- ,l- t°c_ C4., t .��1,7/.i'17 <br /> i <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> $ , I <br /> ❑Owner Given Reason for Denial �tf i/" G —240 J. <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 17 .c,.. OVE ) 1I <br /> Attach to complete rases for the system and submit to the County duly on paper ant iris Cita 81rz x 1011I <br /> �'.in sire 1 "� . + ,, <br /> S<.6 <br /> 1 Burnett County <br /> SBD-6398(R.08/14) • <br /> Land Services Department <br /> 0,4.i' 1 CI 4'10 <br />