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• <br /> N. <br /> yam: zr •�'1 County <br /> fret71�w ;„, Industry Services Division 6t....Nnt <br /> ..ri :t ;„t.: „ ft. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by o. <br /> j . j-a,t-z`?7 (LIoG35 <br /> P.O. Box 7162 <br /> s'ti 1,':'t:. ;/ <br /> ,, .. `4,,-,::.: 4„ Madison, WI 53707-7162 <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 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 �f 5 ckA\ <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. + 't•A re A <br /> R I. <br /> I. Application Information-Please Print MI Information <br /> Property Owner's Name a r,04... .yp.IS-..... -S o$ -Cc'3 <br /> ,J'cv-c/C /44lh7yre — 0Aa&co"J <br /> Property Owner's Mailing Address C Property Location <br /> II 3✓ �1 C $* G Govt.Lot <br /> City,State Zip Code Phone Number y, y,, Section 35- <br /> Trivev 6rav'C Iftljh-rs AI t1/ SS017 circle one <br /> IL Type of Building(chec'c all that apply) Lot# T Y N; R !� E or( <br /> 21 I or 2 Family Dwelling-Number of Bedrooms y Subdivision Name • , <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ,0 Village of <br /> CS Town of J4C-lc son <br /> IIL Type of Permit: (Check Only one hoc on line A. Complete line B if applicable) <br /> A. 13 New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTSSystem/Component/Device: (Check all that apply) <br /> gFcri PiE-a naed In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Koldin=Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> VtDtspecsal/Treatment Area Information: ' <br /> DesignFlory(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 6 0 . •7 ,.GW 9oO '3.oI 97, ,i1, U <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units n U 7, o <br /> N <br /> New Tanks Existing Tanks to 48 o 0 [n w t <br /> Gi <br /> •' .,U 'CZ a <br /> Septic or Holding Tank 4AS-0 Aj- / ti /r-5er <br /> Dosing Chamber_ • i ').0 <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's Signature MP/MPRS Number Business Phone Number <br /> /Z/e•& 441 N s /Z J..1 ,4..L — GAAS8.57 -7%.r=�66— '/S- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1 77ao /4. . '.6J/'r, Sy 53 • <br /> VIII.County/Department �.� �Use Only <br /> 0 Approved ❑ Disapproved $Pen-nit Fee )Date Issued Ag�l Sigma <br /> ❑ Owner Given Reason for Denial i Wig 19 lt ' ,! <br /> IX.Conditions of Approval/Reasons for Disapproval ( JCS+'no-7 4.2_ <br /> fl <br /> © llV -, <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/?a II size 8 20j21- <br /> Burnett County <br /> SBD-6398 (R0313) Land Services Department <br />