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�^ ir' �s. Industry Services Division County <br /> �'I ` \ � <br /> ;;;, D t, 1400E Washington Ave <br /> (=i ��sp ;= P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> • $ Madison,WI 53707 7162 SANS ,Q 2_L Q <br /> a_ g, <br /> C51-22-c 5x <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. IS.04(1)(m),Stats. n <br /> I. Application Information—Please Print All Information ZB32 /O he,-kx a <br /> Property Owner's Name / Parcel# <br /> c&AP,Ar Ko5Mreey o7-oll-Z :a#-/ oIf- -eizax, <br /> Property Owner's Mailing�Address <br /> Property Location <br /> 4"/ q 1( t-4 / e r-r/��F Govt.Lot <br /> City,/St�atte,t�� l Zip Code Phone Number �'EJ y,, NNE y4, Section Z 11 <br /> !'/r/•/re I/�J �/� �57�3 T '76 N: R /5 EorJ <br /> II.Type of Bui ding(check all that apply) Lot <br /> tfI or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block 4- <br /> 0 Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> fit Town of TC,cG,,J <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System 0 Replacement 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 /> 5— (>/ <br /> W , W T 956. 9 9 7.2 <br /> .e <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .0o- <br /> New Tanks Existing Tanks <br /> y H <br /> a V in v to ii. O A. <br /> Septic or Holding Tank 750 s5,,,-., ( , <br /> r x.� t �t e-5e.,- <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Piun er's Name <br /> //(/lP/(r//iJn/`�t)///Jppp1g/ Plumber's Signature MP/MPR7,yS Numberr,Business Phone Number <br /> "754 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> / 2oz <br /> 6A8( 4v�-Al Z ie 44/ 'Jeb - Lit' 569 3 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved PerFee�O Date Issued uing gent Si <br /> 0 Owner Given Reason for Denial 5 e/�7(/} •t/ - <br /> IX.Conditions of Approval/Reasons for Disapproval - <br /> ill 4- aIt -fib-. is Qht i D s -- 0V' C —` <br /> N -Pak/ 4,14 r wee 5hee4- --1D5°L _. <br /> AUG 0 3 7022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than S la x t in sin size <br /> - Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) <br />