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s7r-•;'`zrit. .\ County ;•D <br /> •'•• ``�:r4 Industry Services Division Dµ rn t_-i•--- <br /> /`_:@: ;, i''• 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 Sv-0 2� !�3 <br /> -; )`. :+ y Jim v <br /> �� .;:,-:,-:;r�, Madison, WI 53707-7162 b�f�'�� <br /> <, ,;ram- ," <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govetmnental 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 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. Id 48 j- C` gd O <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ®��7'f-d-37-/5-19-'I o1-coo <br /> Je fF 5he1 rFer • ciao() <br /> Property Owner's Mailing Address Property Location <br /> 93,4g CGl ►ef-f{h Dy <br /> Govt.Lot <br /> City,State Zip Code Phone Number 'id, '9 <br /> Section <br /> Colorevd o S OW j(c,ucle one) <br /> prin1S/Ct>t T 3'7 N; R i Eor(s <br /> II.Type of Building(check all that apply) Lot# <br /> jg I or 2 Family Dwelling-Number of Bedrooms 3 y Subdivision Name • , <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number -3`1j63H 0 Village of <br /> 0 State Owned-Describe Use <br /> v/ a), /p,�e1 0 0 Town of 7 'she L <br /> ie <br /> III.Type of Permit: (Check Only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System tiq Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner - <br /> IV..CypeofPOW iTS.System/Component/Device: (Check all that apply) <br /> ❑Tor.t1§,vrized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> Koldmg Tank ❑Other Dispersal Component(explain) ❑Pretreatment,Device(explain) <br /> V Disper<s'el/Treatment Area Information: <br /> DesigifFldw(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> L 5 ) - -- -- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o "0 c <br /> New Tanks Existing Tanks o v 2 Y E <br /> a C.) 'cisy rn u 3 a <br /> - <br /> Septic or Holding Tank 3oe 0 3000 / Wit-irk )( <br /> Dosing Chamber i ,)•t <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber'sr'/ Signatju/Te MP/MPRS Number Business Phone Number <br /> ,�/G(G- /4 K/nf /2c.ds- Az-c- // -ems e1)•S u <br /> OS/ //S= ,3' 4'-`'J,/S^7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> - 76 D /14,-_>, s" i,i - .ems 7,,-, . 7,-7— _5-9-r"/81 3 . <br /> VIII.County Department Use Only <br /> r Permit Fee Date Issued Is ' g Age t Signature <br /> pp oved ❑ Disapproved P375 ���� <br /> ❑ Owner Given Reason for Denial . <br /> IX.Conditions of Approval/Reasons for isapproval ^ II n <br /> EEE7-\, <br /> Mee, 41( scfloa . <br /> D cg.. 718 <br /> JUL 12 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x l l inches'nine 4 376- <br /> Burnett County <br /> Land Services Department <br /> SBD-6393 (R0313) <br />