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f. :. l <br /> , �, 'i\ Indust Services Division <br /> r�!' \s;� O' County <br /> ;c, 1400 E Washington Ave vole <br /> 1=1 S P ,.:ti.` P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> ' , <br /> tom'+ S Madison,WI 53707-7162 Q 9 <br /> ki <br /> '•• CS --2' --)) (0143466 <br /> Sanitary Permit Application State Transaction Number <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 Services.Personal information you provide may be used for secondary a 66[3�•J iv 1+�i k4 <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Stats. I�R <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> L'/ tovel b7 -2 9o-o-i ay-aoo-rilitv <br /> Property Owner's Mailing Address <br /> Property Location <br /> 77/1 &will s.t tge Govt.Lot <br /> City,State Zip Code Phone Number YE y,, /vi14/+v, Section /7 <br /> 1/0/�/ kJ AI 55 f3� cle one) <br /> T I/Q N; R / ( E or <br /> II.Type of Blinding(check all that apply) Lot# <br /> ;1I or 2 Family Dwclline-Number of Bedrooms Z Subdivision Name <br /> Block n <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> IV Town of V Mb/4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. �y <br /> L7 New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Pennit Revision 0 Chan of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> ge <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> cit Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design SoilA Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(s)) System Elevation <br /> Sou I/Z y '912 qXe <br /> VI.Tank Info I Capacity in Total Y of Manufacturer <br /> Gallons <br /> Gallons Units o <br /> INN Tanks Existing Tanks '2 E9. <br /> Su• -A <br /> U <br /> J U = <br /> �J 0..U y N rn is a a <br /> Septic or Holding Tank /ate /COQ I /T k 1c'du /t e9 Y <br /> Dosing Chamber (/(/ <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plum cr's Name(Print)," Plumber's alumMP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6581 ,v /,w , 1c 641 Je6 - LIt` 5 f 9, <br /> VIII.County/Department Use Only <br /> Permit Feed Date Issued Issuing/A-g t Si <br /> a Approved 0 Disapproved <br /> % <br /> 0 Owner Given Reason for Denial $ <br /> l Uit5 5/?3I a-O- C���^` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> q r 11 r-e4 a[` setba Gtt.5 <br /> CV E il, <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 i2 s 11 es "" `" <br /> N'IAY 1 7 2022 �, <br /> SBD-6398(R.08/14) <br /> Burnett County <br /> Land Services Department <br />