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:q,3D•- , Industry Services Division County <br /> ,,•, 0 1400 E Washington Ave V(^Jel'f <br /> PI `_,S p P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,' S Madison,WI 53707-7162 ^ten I-r�i–2.2i. <br /> ,n' a.5-7---1_ i7LI 437Lt3 <br /> Sanitary Permit Application StatP'ransacnonNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit �� D 7 Z 1D/LSL-G <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. NIP <br /> I. Application Information-Please Print All Information '" i f /33 9citi <br /> Property Owner's Name Parcel# d'a - <br /> Da ve y/v erd20-Z-hV�6-75 s oPevie-ivreee. <br /> Property Owner's Mailing Address/ / Property Location b5�J <br /> /'/Z 3 take 6Oy/A/ Govt.Lot <br /> City,State ` Zip Code Phone Number �j y4, %4, Section / <br /> g5ii, ! of s52,33 0 N; R i trcle one <br /> T E of <br /> II.Type of Building all that apply) Lot# <br /> Il or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of �_ /- f <br /> or Town of 1)114•/tC/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. / New System y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B• 0 Permit Renewal 0 Permit Revision 0 Change of PlumberList Previous Permit Number and Date Issued <br /> 0Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil gMound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 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 /> V66 ° if 5. Kb 976 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units -' ` o <br /> New Tanks Existing Tanks y L `i `, <br /> o a; .n cz <br /> et U in A in u. V a. <br /> Septic or Holding Tank /OG V <br /> W <br /> f , 1 `Dosing Chamber /oo1✓nvJ /J�`/ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plun cc's Name(Print) / Plumber's Si a rcMP/MPRS Number Business Phone Number <br /> T/lQ � "1952/ 7/5--S6d-oZoZ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6S8( ,4' ,4'i 1k ,/ web' L/' 5 693 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued�/ Le in Age im,ar+,/ <br /> 0 Owner Given Reason for Denial $ 3 7S / T. /'2- 1 ! ill., <br /> � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> / <br /> ' Re4 /./37 ir`71-. -; <br /> • <br /> IPEOVEn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 It tri' hes in size <br /> JUL ? 6 2021 <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br />