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N <br /> - ,ez'r itili%:;\ County �� <br /> fYin'''',.. <br /> ..;. Industry Services Division rete t+ <br /> ,lr=' .'. ft. 1400 E Washington Ave Sanitary Permit Number,s t;..4::.',, ° 51 <br /> ry (to be tilled in by Co.) <br /> P.O. Box 7162 r �( ,2z_ t C9 fb�G� <br /> ::: fT, Madison, WI 53707-7162 <br /> g;-s.�' • CS.t z -gg <br /> Sanitary Permit Application State Transaction Number <br /> • <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 t CO Rd.purposes in accordance with the Privacy Law,s.15.04(1)(m),Stets. 29 I <br /> -1 <br /> 1-1 <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> TodCt 14er4-o% o7-oos•Z-4o-i9-09-505.00)-0 -., <br /> Property Owner's Mailing Address Property Location <br /> 1' 1 /rd ev', OAKS C+ _ Govt.Lot <br /> City,State Zip Code Phone Number 9 <br /> t f KI_ / /, 'A, Section <br /> K IrdIP� /k S-I t.! 551)2 (OSI-Z30- 'VP l if T �0 L N; R (1-(circle one <br /> II.Type of Building(check all that apply) Lot# <br /> EorW( <br /> jii.l or2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> 3 <br /> Block# <br /> 0 Public/Commercial-Describe Use • <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> Ip Town of 5c-0't+ . . <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> iekNew System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Nloditication to Existing System(explain) <br /> • <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS,System/Component/Device: (Check all that apply) <br /> ICIVIV Pyeso zed In-Ground 0 Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ fioldngTank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V Dispersal/Treatment Area Information: <br /> Desi Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> L150 . —7 601-13 6,5-0 9Z.5.9s•S, 949 b.S <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° o 7o <br /> New Tanks Existing Tanks w U a di N <br /> a <br /> c o cn' w [iU G <br /> Septic or Holding Tank IOW 1003 I tA, 1 e s e r <br /> Dosing Chamber- . i .)I <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 Si attire MP/MPRS Number Business Phone Number <br /> Zdkard I1opkibl s /� j%v - 225155 I 715-15colc- `-l!S 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Z7T1QO 5+a+e 1a 3S Web ret. wil' 5,1°693 <br /> VIII.County/Department Use Only <br /> Permit Fee co Date Issued Is in�g Ag t Sign xj Approved 0 Disapproved <br /> 0 Owner Given Reason for Denial $ i?5' 6/.6/21 , �r�' <br /> IX.Conditions of A proval/Rea ons fo Disapprovalpit Li VM LS <br /> lee a1 .e pl/t5 <br /> � 1.4 IF r i s cry/, co JUN a 3 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less thou 8 In c 11 inches in siBurnett County <br /> Land Services Department <br /> SBD-6398 (R0313) <br />