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j' �. +r`' industry Services Division County <br /> If?:, D 1400 E Washington Ave A(N e' ✓ <br /> '" • P.O.Box 7162 <br /> (fi :. S - <br /> \ N P$ Sari Permit Number to be filled in by Co.) <br /> ,. ;K, Madison,WI 53707 7162 St 2-2-_-2zz/e <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 /> let: c1 GNq ,7,G0c,L-58-/7 Z7-3 07-0.OY3&'e <br /> Property Owner's Mailing Address <br /> Property Locationj <br /> zz 6/d i Govt.Lot <br /> City,State Zip Code Phone Number /�, Z 7, %, Section <br /> 1 f tel v V' 51187 trcie oa <br /> II.Type of Building(check all that apply) Lot# <br /> T 3� N; R ( E <br /> sr I or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CS1v1 Number 0 Village of((.l <br /> Town of YJdt/14 Ci S <br /> III.Type of Permit: (Check only one box on tine A. Complete line B if applicable) <br /> A. <br /> ❑New System CYReplacement 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 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 /> '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 /> 6-0 • iUU 160 7-92o el*2 6 ga t, <br /> VI.Tank Info I Capacity in Total #of Manufacturer <br /> Gallons Gallons Units Y. 4 <br /> .0U0 <br /> New Tang Existing Tanks .w ^ L <br /> e a '= E di . M is A <br /> a.U in �: re is.C7 a <br /> Septic or Hording Tank /D 00 x n / <br /> ' )( <br /> Dosing Chamber 910 <br /> / �� Z / 7�•f� � ` <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown o✓n the attached plans. <br /> Plu er's Name(Print) Plumber's Si MP/MPRS Number Business Phone Number <br /> 04* 1:144/1/ <br /> PlumFra.'s Address(Street,City,State,Zip Code) <br /> 6&8( /4m*,74-w ?l/ , / tkieb4 Li 559 3 <br /> iVI I.County/Department Use Only <br /> Approved 0 Disapproved PPermit Fee Date Issued Is t Si_.,;' <br /> 0 Owner Given Reason for Denial `O5 10114/?t2 ( • <br /> IX.Conditions of A proval/Reasons for Disapproval / <br /> Tee4- 41 se-�b4,,b F s+ e7i3t€/l+ ) c <br /> - ' EC-EUVEnik <br /> Attach to complete plans far the system and submit to the County only on paper not less than 8 la a II I •.-7 she <br /> I LUi 31 222 I <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br />