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;•*;r:z ,ti County _ <br /> f{ 'I'r4 Industry Services Division b t.t,ev1 e7t <br /> _ :;' 1400 E Washington Ave Sanitary Permit Number(to,s � ,4 °: .. �'1 ry be tilled in by Co.) <br /> P.O. Box 7162 SRN- 2_0- 6 <br /> '4, ,-,t > 2 ua696 <br /> 4LL, / Madison, WI 53707-7162 <br /> Sanitary Pei mit 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 Servies. Personal information you provide may be used for secondary 1 J.03 ..357 a5 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. JJ <br /> I. Applicationlnformation-Please Print All Information !-eicr.s eh /f.,;/ <br /> Property Owner's Name Parcel# <br /> 07-o.i8=.t-40--m- i3-S' oS— 0 03 <br /> G. <br /> /Ctc-- re_4evsovt piI3oo _ <br /> Property Owner's Mailing Address Property Location <br /> /007 sr Pe-71-r r'SoN 7-el. 1 i Govt.Lot ,3 <br /> City,State Zip Code Phone Number /, y,, Section /3 <br /> f?mph e f �' sy‘gp/ (circle one <br /> T y0 N; R /V E o> I <br /> II.Type of Building(check all that apply) Lot# <br /> (l I or 2 Family Dwelling-Number of Bedroorns t3 3 Subdivision Name , <br /> Block# <br /> • <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number El Village of <br /> Town of .SC o 774- <br /> III.Type of Permit: (Check Only one box on line A. Complete line B if applicable) <br /> A A. 2 New System <br /> y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision <br /> ❑Change of Plumber ElPermit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..{'ype of POWTS.System/Component/Device: (Check all that apply) <br /> ❑-Non.Pressurized In-Ground 0 Pressurized In-Ground 0 At Grade R Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Ifoldia Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> WDispersal/Treatment Area Information: _ <br /> Desggi Flaw(e d) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units . ` o <br /> New Tanks Existing Tanks -. o v 2 t8 <br /> c.0 cn y d w0 a. <br /> Septic or Holding Tank Z bo o _ imb <br /> Dosing Chamber_ . • <br /> C Jt� / (. 7 � t -)r <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 /> R/c./c 74%,o%n s / l41 4 )04-reS/ 7/5= 864, -9/s-7 <br /> Plumber's Address(Street, ity,State,Zip Code) <br /> • <br /> j 7 7G 0 /4,, j..§"" 7V-c4,s''ry 1 ' L ..J 6 ?.3 <br /> VIII.County_/Department Use Only <br /> fr <br /> Approved 0 Disapproved $Permit Fee Date Issued Issuing Age Sigma <br /> ❑ Owner Given Reason for Denial1/10/2'29 � <br /> IX.Conditions of Approval/Reasons for Disapproval C <br /> ' osk ec\C ak\ sekbuck-5 t © I l V E m <br /> � rn <br /> a- <br /> JAN 0 6 2U'L2 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x ll'L:he r size Iffr <br /> Burnett County <br /> SBD-6393(R0313) Land Services Department <br />