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:', c•z'4r�,\ County - <br /> r ''-• ''`-:r U <br /> = Industry Services Division t.A ►"rt ttt <br /> ;V , #` r;:.:'., 1400 E Washington Ave <br /> ,r : Y 4.. , ,, 9 Sanitary Permit Number(to be tilled in by Co.) <br /> .. P.O. Box 7162 Sly-A2-1 38 <br /> ' ti_;:-fir.,/ Madison, WI 53707-7162 <br /> NA;;;;,;u3Ve c5T to—l[v <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 governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO WTS 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 f � <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 765g v0. p 144- e a <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> ErtG EriG,sovl 07��o-�-yo-l6-,�o-S/S-'�e�l <br /> bl iobQ /,�/��Property Owner's Mailing Address Property Location /Z Z <br /> l 3 0 6 15 11 191"t- N t Govt.Lot <br /> City,State Zip Code Phone Number y, Va, Section <br /> Ce71,4. e 1 A H �41 N SS-L?rO`, circle one) <br /> II.Type of Building(eteck all that apply) ? Lot# T y� N; R ! E or� <br /> VI or2 Family Dwelling-Number of Bedrooms 3 Subdivision Name , <br /> Block# <br /> • <br /> 0 Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> 21 Town of Ca/L/otr,a <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> xi New System 0 Replacement System 0 Treatment/I-folding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. D. Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS.System/Component/Device: (Check all that apply) <br /> .NFn Presiirized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ €{gldmgTank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V..-Dispersal/Treatment Area Information: <br /> DesigifFldw(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> LIso - , 7 6'/3 (So 53. o • <br /> VI.Tank Info Capacity in Total #of Manufacturer u <br /> Gallons Gallons Units a V. U 0 <br /> New Tanks Existing Tanks e o Y 2 0 <br /> c.U rn H ri] ii F. a. <br /> Septic or Holding Tank /Odd /vuc, / t/./tc St°Y X <br /> Dosing Chamber_ i <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 /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 7C ; . 3 3 (iv-e bsh--,, 1't,.3— 5-`1 693 . <br /> VIII.County/Department Ilse Only <br /> pp oved 0 Disapproved Permit Fee Date Issued Is o • ent 3. , ;t„. �� �-- tt/ <br /> A r2 5 . 71 / • <br /> �( 1-7 <br /> 0 Owner Given Reason for Denial dT <br /> IX.Conditions of A proval/��asons f r Disapproval <br /> 1'nee-4-a S61'�ath,-7 i 7a/ i ,J U N 2 2 2022 <br /> r1-1a5 <br /> Burnett County <br /> Land Services DRpartment <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8(/2 a i l mall m brie <br /> SBD-6398 (R0313) <br />