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-4Igiaiz7:4-‘ County <br /> 7' ' • '`''r+ Industry Services Division )3tAen e <br /> ,it y ` r•.J.: ;, . 1400 E Washington Ave Sanitary Permit Number to.,ti`,,4 ;: 'i ry ( be tilled in by Co.) <br /> s t y P.O. Box 7162 •- -/16" <br /> � .rx, Madison, WI 53707-7162 ��6p td� <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 Servies. Personal information you provide may be used for secondary AO" <br /> D <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information (./of ka. /?d <br /> Property Owner's Name Parcel# <br /> 07-0l6-�1•J9-17-IS yod -oao <br /> M:ke St 1i,n;ft p l/oo/ <br /> Property Owner's Mailing Address Property Location <br /> /0 9 Lill /8/5 t LH N`V Govt.Lot <br /> City,State Zip Code Phone Number , , <br /> /, <br /> /, Section If <br /> t-1/' 1Ztvte /Y)N 5S330 (circleonel <br /> II.Type of Building(check all that apply) Lot# T 3 i N; R 17 E or <br /> 1 or2 Family Dwelling-Number of Bedrooms 01 Subdivision Name <br /> Block# <br /> • <br /> 0 Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSNI Number p Village of <br /> IG Town of LiviColn <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System 0 Replacement System ❑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 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 Ple st rued In-Ground ❑ Pressurized In-Ground ❑ At Grade El Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ €fofdus0ank El Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V Dispersal/Treatment Area Information: <br /> Design-Fla*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 . 5- (CO (,0D q0 •s— <br /> VI.Tank Info Capacity in Total #of Manufacturer , <br /> 11 Gallons Gallons Units v U t <br /> New Tanks Existing Tanks . o y, 2 11 a 58 <br /> c,o in cn rn Cc-co a. <br /> Septic or Holding Tank 7Se) -7,-0 t-v 1 e Sep' <br /> Dosing Chamber- ' .) <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rik Ayop/cli,.f /Zc.ti. %'. GI,Lres/ 7iS-8(o6-- 13"7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 01% 774 D m fil .e 5fer w <br /> � 5 `l'3 9 3 <br /> VIII.Count,Z/Department Use Only <br /> Approved ❑ Disapproved VS <br /> Fee Date Issued [ o A ent Signii <br /> 0 Owner Given Reason for Denial � ‘ � v��/007 • •. , <br /> IX.�Conditions of A pcoval/12Je, sons f r Disapproval betc rwsiz ^ ^rt IE c <br /> Cam' `7!901 <br /> JUL272022 ith <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 all inches ti(J r <br /> Burnett County <br /> Land Services Department <br /> SBD-6398 (R0313) <br />