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fKa��-:r,j, <br /> ;1f� �,;� Industry Services Division County <br /> t;;', p 1400 E Washington Ave Arf vdi <br /> li'J :. S ' P.O.Box 7162 <br /> `, ; � PS Sanitary Permit Num.�jer(to be filled in by Co.) <br /> An .��a Madison,WI 53707 7162 50 �a Z_.C.L L�/ <br /> c5�2z 59 r <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stets. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Bcoc/ Nel ,,v zz96y ANA4M I L J <br /> Property Owner's Mailing Address Property Location <br /> Z570 lot Govt.Lot Z <br /> City,State Zip Code Phone Number Z <br /> ��/J +, 1/4, Section <br /> W r�eWt°(,tf I V (i to 65116 T �� circle one <br /> H.Type of BuildingN; R I E o <br /> I,,�I,r.� p (check all that apply) Lot# <br /> l 1 or 2 Family Dwelling—Number of Bcdrooms II <br /> 60 kt Subdivision Name <br /> Block y <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> ErTo\1n of PO/vi 61j <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System QfReplaccment System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B- 0 Permit Renewal 0 Permit Revision 0 Change of PlumberList Previous Permit Number and Date Issued <br /> 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> Ei 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 Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 400 . -7 /67 857 997 4 QS:S <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> U O y <br /> New Tanks Existing Tanks u U VI <br /> aU in in tZa a. <br /> Septic or Holding Tank /2t <br /> Dosing Chamber 75) -gem 1�il f V <br /> VII.Responsibility Statement <br /> --I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu Name(Print) Plumber's Signa c G�`// %„ MP/MPRS Number Business Phone Number <br /> Q e/ / 86/9541 7/1--fg coo <br /> Plumhrir's(QAAddress(Street,City,State,Zip Code), t <br /> Gt'J8/ /re?v7/i nl Z!e 1��/ �Vt 4 L 5 f t, <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued Iss i Ag t Sign <br /> 0 Owner Given Reason for Denial 5IS10 , 4 . 2Z <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> M'- ✓bed 3,} fsctb„ - Seper4.-fi�si qv �t'Minl - 1- CC 2 <br /> 1114 © [EnqIE -\71 <br /> tI <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8[2 x 11 hesitIrsizcgil j Z 4 uZz Jt <br /> a� I <br /> 1 <br /> Burnett County <br /> SBD-6398(R.08114) Land Services Department <br />