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a`FY^ars'evr o Industry Services Division Count <br /> a2y Ie . �1 4822 Madison Yards Way � r f <br /> '� < Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> b <br /> p:i i, P.O.Box 7162 t5 — 9.-`79 <br /> Pr rasroan+°ts Madison,WI 5 3 707-7 1 62 `,(�3i,(L"7 <br /> Sanitary Permit Application State Transaction Number " r <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 fonns 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. t� //az <br /> I.Application Information-Ple se Print All Information Z 7- ��/ SaKd Cti <br /> Property Owner's Name C Parcel# <br /> Property Owner's Mailing Address ( Property Location <br /> / 1 <br /> 2- / d\ "'`--� ej- Govt.Lot <br /> City,State t / Zi Code 7 Phone Number <br /> tit k- .J 7-l C u/) 01 /1/ !1'., .c ', ection <br /> II.Type of Building(check all that apply) Lot# T 33 N R or W <br /> 0 .r 2 Family Dwelling-Number of Bedrooms---3' / Subdivision Nam <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of �' <br /> V33 /own of L� ��/an /`� �(.// <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. New System j�- e lacement System Other Modification to ExistingSystem(explain) Additional Pretreatment Unit(explain) <br /> ❑ Y Tyt,�P Y C Y ( P ) ❑ ( P ) <br /> B. olding Tank 4❑l In-Ground ❑At-Grade ❑Mound ❑Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. 0 Renewal Before ❑Revision nChange of Plumber ❑transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Degi Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 7517 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units p t o ,z, o <br /> New Tanks Existing Tanks v c -o <br /> a.U n vi w 0 a. <br /> Septic or Holding Tank -- <br /> Dosing �sv /�. nI <br /> Dosing Chamber U ❑ I❑ <br /> V.Responsibility Statement-I,the undersigned,a . r,'responsibili't`y for installation of the POWTS shown on the attached uplans. <br /> Plum er's Name(Print) P1u�•• is Signature MP/MPRS Number Business Phone N ber <br /> Plumber's ddresstreet,City,State,Z' Co. i �� <br /> � �� f 5-7_, <br /> /'�- -(���- J&L t,� v[ <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee �= Date Issued Is 'n1ig ge Signatu <br /> ❑Owner Given Reason for Denial 375 S/!l/ -? <br /> Conditions of Approval/Reasons for isapp <br /> Ple - all 5 <br /> tit 137 19 ' 4 <br /> E LC ll <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 r/2 x 11 i ize <br /> MAY 6 2022 <br /> SBD-6398(R.03/21) <br /> Burnett County <br /> Land Services Department <br />