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„;:' u- '` Industry Services Division County <br /> ;s', 1400 E Washington Ave 6 or/ ./r -- <br /> Isi S7 P.O.Box 7162 <br /> ron��tary'—a Permit Number(to be filled in by Co.) <br /> :L;\ PS Madison,WI53707-7162 • Sv 134, <br /> ` ` CSC 21—7Li 43J7 3 <br /> Sanitary Permit Application state ransaction 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 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).Stets. <br /> I. Application Information—Please Print All information ” -4ae•C JR" n , <br /> Property Owner's Name Parcel# 3&/3D/ <br /> Property Owner's Mailing Address <br /> j� Property Location <br /> / - /e /`/'J.// • Govt.Lot <br /> City,State Zip Code Phone Number y,, % Section , <br /> 'I! 1 �` (circle one).- <br /> .' \/, L t i ..-„ <br /> - T r N: R ,` E orZp <br /> II.Type of Building(check all that apply) Lot# <br /> VII or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> 0 State Owned—Describe Use CSM Number 0 Village of <br /> .❑Town of ! ..r;-j� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. rl <br /> New System Q }' 0 Replacement System 0 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 /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Q 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.DispersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> _ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units S -Eu <br /> New Tanks Existing Tanks - g V u <br /> E..-U in 5.. a rL v a <br /> Septic or Holding Tank //IAj\ J l r�w <br /> Dosing Chamber �(/✓V F I <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plun cr's Name(Print) Plumber's Sienatu MP/MPRS Number Business Phone Number <br /> . T 114Ad <br /> � �/�/� ��t�s�/ 7/s--se-ate <br /> Plumbers Address(Street,City,State,Zip Code) <br /> G88/ AWriv t le 4/ Geist LA. 54/139 <br /> VIII.County/Department Use Only <br /> lii <br /> .Approved ❑ Disapproved Sermit Fee Date Issued Issuing Agent Signature <br /> 0 Owner Given Reason for Denial 37•S .S . Z/ w• /g <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> LLl_ IVE <br /> Attach to completeplans for the system and submit to paper P )►tc County only on a cr not less than 8 � hes in size <br /> ( at 52.4/41/452- ,_,_„, 15(-1-clr.'5 MAY - 32021 <br /> SBD-6398(R.08/14) C r `a U(I ' Burnett County <br /> �(�. Land Services Department <br />