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`''V-�--<iti Industry Services Division County iziriy- 1400 E Washington Ave XtJaiC# <br /> Rsl S '= P.O.Box 7162 <br /> p� Sanitary Permit Number(to be filled in by Co.) <br /> -`'.h Madison,WI 53707-7162 S`RN- 22— 57 b t /' <br /> vi.�,a�' C S t -,92 58. <br /> Sanitary Peim it 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),Stats. TGY> �� ,� <br /> I. Application Information-Please Print All Information 2 3 / ip( K/C/�/ <br /> Property Owner's Name Parcel <br /> To4Ai Piot,'e d7-w6-2-%'-47-z9.5- a/-aoo-orure <br /> Property Owner's Mailing Address , Property Location <br /> 667K Gibe* lZ/�/ Govt.Lot <br /> City,State i Zip Code Phone Number <br /> j4 . _/ ,.V•` %+. '/., Section 2 ei <br /> JrGf1/ I, 5+106 - T 3 i' ,( rcle one) <br /> II.Type of Building(check all that apply) Lot _N R ( E or,V <br /> NI I or 2 Family Dwelling-Number of Bedrooms Z / Subdivision Name <br /> Block R <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CS\1 Number 0 Village of <br /> 9945 vz5 P/0 ) �Towm of I714in.i,,L15 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. rim <br /> Lp New System y 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 Change of Plumber 0 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 /> LP 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 /> VI.Tank Info Capacity in Total K of Manufacturer <br /> Gallons Gallons Units = <br /> New Tanks Existing Tanks a _`u U = <br /> L V % en <br /> c, O E 7 ru <br /> a U in N ti rr C7 a. <br /> Septic or Holding Tank ' .. <br /> 76-f) 750 I tW ee tC/ y <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pfat. <br /> lum cr's Name(Print)c% / Plumber's S'_ rc MP/MPRS Number Business Phone Number <br /> 8619V-Plu -1�'�! i�ii O2oZ <br /> mb is(AAddress(Street,re City,State,Zip Code)J p j <br /> 658/ /Aim"' LOe ,/ UVe/� VI- 54/8 , <br /> VIII.County/Department Use Only <br /> AApproved 0 Disapproved Permit Fee Date Issued >ss 'nAge Sigma <br /> 0 Owner Given Reason for Denial S 1/d5 �'2t2/v2 r� C; ` -yt� <br /> IX, nditions of App ovallRe ors For Disapproval <br /> sol <br /> nue4- Ott S e/f19clic4 <br /> APR 2 1 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 litchis'.a ilECEBVIE <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) I,2 ( -(.19 <br />