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2s �r County <br /> Industry Services Division Burnett <br /> t ® 1 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> Pa <br /> P.O. Box 7162 <br /> ' Madison,WI 53707-7162 �`�� •I <br /> - <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.15.04 1 m,Stats. Park Street <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# 07-O;LO-a'YO -i4'S <br /> Robert and Annamarie Lee <br /> 3a0 -Oq'tSpro <br /> Property Owner's Mailing Address Property Location <br /> 203 Via Antonio <br /> Govt.Lot <br /> City,State Zip Code Phone Number %, h, Section 19 <br /> New Bury Park,CA 91320 763-229-2788 (circle one) <br /> T40N R16EorW <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 3 2 Subdivision Name <br /> Jensen Lakeshore/Yellow Lake <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> O 10` `X! ® Town of Oakland <br /> III.Type of Permit: Check only one box on line A. Complete line B if applicable) <br /> A. ® New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S stern/Com onent/Device: (Check all that apply) <br /> ® Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ 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 Application Dispersal Area Required(s0 Dispersal Area Proposed(so System Elevation <br /> 450 Rate(gpdsf) 642.9 650 93.5 <br /> .7 <br /> VI.Tank Info Capacity in <br /> C d U <br /> GallonsTotal #of <br /> Gallons Units Manufacturer u <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank 1000 1000 1 Skaw Pre-Cast ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber 1 ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility fm installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Thomas Gustunt AV 227618 715-658-1344 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> N13450 937`"Street New Aubum WI 54757 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee UD Date Issued Issuing Agent Signator <br /> ElOwner Given Reason for Denial $ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECEIVE <br /> nR nt%-r A - ____ nn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 12 a a <br /> incift <br /> in s <br /> BURNM COUNTY <br /> SBD-6398(R03/14) ZONING <br />