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\. <br /> rr4;sz:;zf,, County <br /> ‹ =„4 Industry Services Division /Div r r1 <br /> ,mod .:. •;,;. . .sY. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> "'' `'' 1l P.O. Box 7162 <br /> .. 1'i "$ k! Madison, WI 53707-7162 ` ANI —°Z�'—d� <br /> ;= f & 2/ 67 G3/V <br /> State Transaction Number <br /> Permit Application <br /> Pwrs —o.Z.oD,04/_ : <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is.requred 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 6,3 17 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. /� <br /> I. Application Information-Please Print All Information Oa v/S a,"i tie <br /> Property Owner's Name Parcel# g./b_d 6_y-O�l- O o6 <br /> /om L.oh,fir, o7- a►S`a- 3 <br /> --#izez.f- o 15 000 <br /> Property Owner's Mailing Address Property Location <br /> !) 5 -/m gel Govt.Lot <br /> City,State Zip Code Phone Number y, 'A, Section oI b <br /> t/t/t p pit o in N cr0 ci d ,(circle oney, <br /> II.Type of Building(check all that apply) Lot# T N; R E o <br /> RII or 2 Family Dwelling-Number of Bedrooms al <br /> L71 Subdivision Name <br /> Block# <br /> • <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSIvt Number ❑ Village of <br /> 0 Town of jy1 e,e iov, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) • <br /> A. <br /> Et New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B• ❑ Permit Renewal ❑Permit Revision ❑ Chancre of Plumber ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTSSystem/Component/Device: (Check all that apply) <br /> ❑Non Pressurized In-Ground El Pressurized In-Ground El At-Grade 1] Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dispersal/Treatment Area Information: ' <br /> DesfguTlow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> Soo _ /. /d 300 336 17, 3 / <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units a i o T B <br /> New Tanks Existing Tanks o <br /> cTA <br /> `.0 c/a rn rn i1.o a. <br /> Septic or Holding Tank yo ryyo � <br /> Dosing Chamber.. • d ( /w l e <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 /> /?I C/G /41)/e-/el / /.) c-t-n,, rig' (44.5-9 r/ 7'S= 866 9%0-7 <br /> Plumber's Address(Street',City,State,Zip Code) <br /> al77Go y../ .hr 1-ve.sf/ ,. w 7- -5-7` 89�' <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved <br /> Permit Fee Date Issued Issuing Agent Signature _. <br /> CI Owner Given Reason for Denial $ 37s Z *.'S..l� <br /> IX.Conditions of Approval/Reasons for Disapproval rf' I (ti 15146 <br /> flL © llV <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 l/s x 11 inches lire <br /> IAN 2 5 2021 <br /> Burnett County <br /> SBD-6398(R0313) Land Services Department <br />