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/4' 's',i'., County <br /> r <'.' ''% Industry Services Division i3t t r <br /> y=��ill'..,''''.: '.� n Ott <br /> t ,.: ,. '.. 1400 E Washington Ave sanitary Permit Number(to be tilled in by Co.) <br /> ` r'' •• P.O. Box 7162 <br /> '{n�. '/''$ ✓i, Madison, WI 53707-7162 � 2 �u3�!16 <br /> State Transaction Number <br /> Sanitary Peiiiiit 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 POINTS 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 4356 15 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. (A/i Id h get <br /> I. Application Information-Please Print All Information °"f'�'" <br /> Property Owner's Name Parcel# <br /> a,-0/k,i1-les/5-Pf- Yoa- 6 <br /> ae- <br /> 30 hh 66;I1 3 oilAao <br /> Property Owner's Mailing Address Property Location <br /> /-0 eoX / i q Govt.Lot <br /> City,State Zip Code Phone Number /, %, Section pr st <br /> IN ebs v Gar Sit 853 circle one <br /> II.Type of Building(check all that apply) Lot# T �!d N; P. /� E(:))circle <br /> RI 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name , <br /> Block# <br /> • <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> do 4 AA,4 /7oi ® Town of JAC ksa h <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. h. <br /> A New System <br /> y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other 1v[oditication to Existing System(explain) <br /> B. ❑ 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.Typeof POWTSSystem/Component/Device: (Check all that apply) <br /> g1•Tonakibrrized In-Ground 0 Pressurized In-Ground 0 At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 im of suitable soil <br /> ❑ Fioidm=Tank 0 Other Dispersal Component(explain) 0 Pretreatment,Device(explain) <br /> V.Dispersal/Treatment Area Information: " <br /> DesignFIow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> `7s a . 7 "3 6'5-2, 93.a Y-o /p?" e <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units a o <br /> New Tanks Existing Tanks o v _m <br /> c,U m i v] lE C7 n. <br /> Septic or Holding Tank /0mo f000 / �/eft✓ . <br /> -Dosing Chamber- J� j :)r <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/MPR¢SNumber Business Phone Number <br /> 12/c./G hie,/ IrS / N' O)�J N8-5/I 7/5-- e66 - 9/ 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> a 776o h't4 , 3.$ Gti eb. 4 lf/..j" T erg? <br /> VIII.County Department Use Only <br /> 04'pproved ❑ Disapproved Permit Fee L� Date Issued Issfuj'`g Agent igna <br /> ❑ Owner Given Reason for Denial $3 75--- 3/e 12'a v • <br /> IX.Conditions of Approval/Reasons for Disapproval E I V L'� <br /> S yS�e+cy\ e\c (Or;on r>no s)( b L `'13. c. or \owe f <br /> flee-4—�,ll se f4, , ©b113i,L. <br /> _MAR 2 3 2022 J' <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inones in e 3 3-7; <br /> Burnett County <br /> Land Services Department. <br /> SBD-6398 (R0313) <br />