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:!,.4; Lr.` County? <br /> !' ': '' =„= Industry Services Division P r"n f 7.74 <br /> i ;P 4f;,;: 'A.• 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> 4. `i P.O. Box 7162 l'AIV, .:.2 2 3/ kg3� f <br /> 4 : ,.-it rsf Madison, WI 53 70 7-7 1 62 <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> o; ota-l-Sro-ls-dy-s-o3-ool- °Moe <br /> wl 0-,:I -11-19 —ol9/ O <br /> Property Owner'sr' Mailing Address Property Location <br /> 017 3 / L4eJv1 ?J' Govt.Lot 1- <br /> City,State Zip <br /> Zip Code Phone Number /, '/<, Section df <br /> I/1/ec7 S�f,i 1/t'j S f9 T (circle47'0 N; R /y E one), <br /> II.Type of Building(check all that apply) Lot# <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms 3 1 r t I. Subdivision Name • , <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number $'71/ .0 Village of <br /> V..), A. Si de 67k07( ®To+vnof �CO <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System 0 Replacement System <br /> yp y 0 Treatment/Holding Tank Replacement Only 0 Other Modification 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. 'ypeof POWTSSystem/Component/Device: (Check all that apply) <br /> `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 /> ❑ EfoldmgTank 0 Other Dispersal Component(explain) 0 Pretreatment,Device(explain) <br /> V�Dispersal/Treatment Area Information: <br /> Des igi FIdP,(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> YSo .7 6y3 (o96 93. <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> v <br /> Gallons Gallons Units o ,, u <br /> New Tanks Existing Tanks 4 o aV, ti 7 dt m 1 <br /> o U v) y rn G.c..c7 a <br /> Septic or Holding Tank oQ <br /> Dosing Chamber_ i -) <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/MPRS Number Business Phone Number <br /> f/G/C f/,o/e/r, 1 / 4/ % -- aIal. -5.5--/ 7A5•(fOk- /5-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .1776d l 15 i-e,y s'c‘ 1-, - e??3 <br /> VIII.County_/Departmen Use Only _ <br /> Approved ❑ Disapproved Permit Fee Date Issued Is g gem ignatur <br /> ❑ Owner Given Reason for Denial L <br /> IX.Conditions of A proval1Reasorl for Disapproval +] <br /> • <br /> APR 05 2022 <br /> El 1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 s inc s in size <br /> eie '0`l 13% — Burnet 6Ounty <br /> SBD-6398 (R0313) /�a,5U,- <br /> Land Setvid4$Department <br />