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N <br /> ., :.a.r County <br /> t XT': '''I''''4 Industry Services Division � LAV'.N e 14 <br /> ip,,_art :•pt: :,i; „-fr. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> .. r; P.O. Box 7162 v A-N-z z.•--2,13 (.��' /� <br /> ` r4i P�adison, �/I 53707-7162 <br /> •r,v ai l cJ we.C 114 q <br /> State Transaction Number <br /> Sanitary Permit Application <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 POGVTS 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 d 70 70 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information ���� /�°`t�' ��Js <br /> Property Owner's Name 1 Parcel# 7 <br /> m r G11 ' ! Ck10.5f/ti PI c3 7_°r�``1—ya-l.�l .a i000 s <br /> Property Owner's Mailing Address _ Property Location <br /> )l / %S Z0 d 1 4 G .5 t' IV ,ram <br /> . (� Govt.Lot <br /> City,State Zip Code Phone Number //,,LA, 'A, Section / O <br /> �/ oril i i”, it Ai 75 CJ� T 7�N le e; R / or <br /> ® <br /> II.Type of Building(check all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms 1 .5 Subdivision Name <br /> Block# • <br /> 0 Public/Commercial-Describe Use • <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> )(Town of��ri <br /> III.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 Ivloditication 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 POWTSSystem/Component/Device: (Check all that apply) <br /> ZNon P,es zed In-Ground ❑Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> - <br /> ❑ Pfoldin Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V<Dispersal/Treatment Area Information: <br /> Desi FltivRa <br /> te(gpdsf)Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> i, <br /> - <br /> . 7 693 &CO S • ) <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .0o <br /> New Tanks Existing Tanks E o aa,, Q - m <br /> C,U cn Ti Co ii 0 G- <br /> Septic orHolding Tank /(> 0 /b&0 ( h `///v4)40/ X. <br /> Dosing Chamber- 1 .a t <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 IMIP/MPRS Number Business Phone Number <br /> R/G/e- f/4,4 iH r /2 rr a.,,,,,-„ 7, s- ‘—Ws-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> di 7760 gt 17 �..s' Gv-ebsf e. w S`t8 c? <br /> VIII.Coun /Department Use Onl i <br /> Permit Fee ce2 Date�Isssued Is ing •ge t Sigma , <br /> kr Approved 0 Disapproved <br /> ❑ Owner Given Reason for Denial I?5 q ?/?.)- ii • / <br /> IX.Conditions f Appro al/Reaso for Di approval <br /> a ITECIEDVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 V?x 1l i es ;ize 1,142C <br /> ` <br /> Burnett County <br /> Land Services Department <br /> SBD-6398 (R0313) <br />