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N <br /> -e• `-'5`f County <br /> ier—:, • `'`t+ Industry Services Division Xterl e <br /> yam':'.,:_;;.. <br /> , ��: i4r§:`.: P' 1400 E Washington Ave SanitaryPermit Number(to <br /> 'ji'k`t'>4.i` ° rq <br /> P.O. Box 7162 be tilled in by Co.) <br /> 44: ,•: -: *:, Madison, WI 53707-7162 (c"►3 J0 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Win 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 Servies. Personal information you provide may be used for secondary t Sd 6 <br /> purposes in accordance with the Privacy Law,S.15.04(1)(m),Stats. 0► <br /> I. Application Information-Please Print All Information .. ttfe- /•al 3S <br /> Property Owner's Name Parcel# <br /> �d�►+� SG1tt.trvtakrr o7-oao-d-1/0-14-'.to-?d1 -ooa <br /> - otJo0o <br /> Property Owner's Mailing Address Property Location <br /> A 03 9 ,..0.4-fe- Re( 37 Govt.Lot <br /> City,State Zip Code Phone Number , , <br /> /, /,, Section A o <br /> (Al dS ft,/ Lv_ e 93 (circle one <br /> T 4/0 N; R /6 E or460 <br /> II.Type of Building(check all that apply) Lot# <br /> CII or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> �-y <br /> LY Public/Commercial-Describe Use P44** w 1.re Aokse <br /> ❑ City of <br /> ❑State Owned-Describe Use CSNI Number 0 Village of <br /> gi Town of 6,k/d4,d• <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. .. <br /> New System 0 Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner - <br /> IV. 'ypeof POWTSSystem/Component/Device: (Check all that apply) <br /> X.Nbii Press ized In-Ground 0 Pressurized In-Ground 0 At:Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ FldldmgTank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V-Dispersll/Treatment Area information: ' <br /> Design low(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 17J,_, c' , S- 3Lis Gvo 73 .01 <br /> VI.Tank Info Capacity in Total #of Manufacturer u <br /> Gallons Gallons Units o 'n <br /> New Tanks Existing Tanks w u " ,3 y m c <br /> C U m ti rn u:to w <br /> Septic or Holding Tank 7-Q 7s0 <br /> / k J&Sty' `/ <br /> Dosing Chamber_ �C r -)' <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> lz/tf44 11-/opkin✓ /Ze.. .4.1 f/ d•oh r - 7is-56 - 4'Ic <br /> Plumber's Address(Street,City,State,Zip Code) <br /> • <br /> Q77Z00 /./.7 75- lrvths , V S-9c9y <br /> VIII.Countypepartment Use Only . <br /> Permit Fee Is win A ent <br /> Approved ❑Disapproved $ �^�� ���Date issued�� g _Siang <br /> fSK <br /> -/1 <br /> ❑ Owner Given Reason for Denial 4r ;J'.', -Ti �; -, <br /> IX.Conditions of Approval/Reasons for Disa proval I d' N...." --� V <br /> 6i. 3-)sc° r <br /> MAY 2 2022 j <br /> Attach to complete plans for the system and submit to the County only en paper not less thou 8 I Si 1l inches in Burnett COUllty <br /> II <br /> I Land Services©eperbinowntt <br /> SBD-6398(R0313) <br />