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fri% Safety and Buildings Division CountyTAJ tJ <br /> 7. 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be fine¢in co.). <br /> F $�' ,�d Madison,WI 53707-7162 Sw-A,(-3 t o lv C�(o�1 <br /> State Transaction Number <br /> Sanitary Permit Application <br /> 1 accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> a 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 /> ne Department of Safety and Professional Servies. Personal information you provide may be used for secondary p� �,i ,ti U 1 Q� �p / <br /> ut oses in accordance with the Privacy Law,s.13.04(1)(m),Stars. �/ a ^,� 1 p��f� <br /> . Application Information—Please Print All Information DA i> {c <br /> 'roperty Owner's Name Parcel# I <br /> j 1IA V C Q2oC 1c Z- `�7C1) fvy - ,Oo 1100 <br /> 'mperty Owner's Mailing Addretg Property Location <br /> 866 , yq T " -s-r Govt.Lot G <br /> �ity,State Zip Code Phone Number 'A, V4, Section 1 `) <br /> C4 !` 5 y C f /� i cache one) <br /> V�I.tV�� �) / c-�V T. 9V N; R 1) Eort <br /> [I.Type of Building(check all that apply) Lot# <br /> ,,,,{{ 2 <br /> iy.l or 2 Family Dwelling—Number of Bedrooms 33 -a 3L Subdivision Name Q n`� p n �y'�iJ�‘� <br /> Block# n- one i RIo RQ P -ro VO i 6 G- <br /> Public/Commercial—Describe Use 'fl1 City of <br /> CSM Number ❑Village of <br /> ❑State Owned—Describe Use Town ofC <br /> III.Type of Permit: (Ca*4'k only one box on line A. Complete line B if applicable) <br /> A. $New System ❑Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> List Previous Permit Number and Dace Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> tit-Non-Pressurized In-Ground 0 Pressurized 1n-Ground 0 At-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank D Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: 1 55 Ai is K. LI CO Atnuel‹.S <br /> Design Flow(gpd) Design Soil Wcation Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(af) System Elevation <br /> c <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units n . j'• _ y 0 <br /> New Tanks Existing Tanks d = B R.1 <br /> o if <br /> Septic or Holding Tank 7 50 —]5 Y® 1 ese� X <br /> Dosing Chamber lJ <br /> VU.Responsibility Statement—I,the undersigned,assume responsibility for in fellation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P ' Si e, v MFber Business Phone Number <br /> PI ber's Address(Street,City,State,Zip Code) <br /> tat 81)1, 5 6 S 13R,G,s. � 1) 5.ya40q <br /> VIII.County/Department Use Only t Si <br /> Permit Fee Date Issued/ I- 'a• _ gna' <br /> 0 Approved ❑Disapproved S � ��� 1 OI"J�I '�' �/ �j� <br /> ❑Owner Given Reason for Denial 1 / <br /> IX.Conditions of Approvai/Reatoits for Disapproval �f <br /> etc&A-V. W fnvSi. lmee s Se:A'ba.�ks'• > 5o' �'roNI we\\ ] v <br /> E7 <br /> > ,o' Prowl sick)c,4vcc. <br /> s` From dot hoe. I OCT - 8 2021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x 11 inches size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) C4 # it 2.2c1 <br /> 0u7Cs' <br />