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Industry Services Division County <br /> 1400 E Washington Ave ^/ <br /> p <br /> anitary Permit Number(to be filled in by Co.) <br /> =i S P.O..Box 7162 <br /> Madison,WI5370'7 7162 <br /> Sanitary Pemlit 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 fumes 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.15.04(I)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> A �/` 4/J oZ0y1 Z•��1� -Z a/-POO-A16a,9 <br /> Property Owner's Mailing Address G Property Location <br /> !z (� 440 Govt.Lot (� <br /> City.State Zip Code Phone Number %. Section CJ <br /> circle o <br /> II.Type of Buildi (check all that apply) � Lot <br /> T_ N; RE <br /> i or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block✓r <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSIvI Number ❑Village of <br /> Town of <br /> ill.Type of Permit: (Check only one box on Une A. Complete line B if applicable) <br /> A. <br /> ❑New System WReptacement System ❑Treatment/Holding Tank Replacement Only ❑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 Onmer <br /> IV.Type of POWTS S stem/Com onent/Devlce: (Check all that apply) <br /> ❑Non-Pressurized in-Ground ❑Pressurized In-Ground ❑At-Grade ®Ivtound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Deuce(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ys ,0 <br /> Aso yso 9g.�" <br /> VI.Tank Info Capacity in Total R of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tattles <br /> Septic or Holding Tani: 400 <br /> Uasing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plates <br /> Plu er's Name(Print) Plumber's Si MP/MPRS Ntupber Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Codc) <br /> 6 ivy l� / �1ei� - c„1t• <br /> VIII,Coun /De artment Use Only <br /> proved ❑Disapproved Permit Fee Date Issued Issu' A Signature <br /> ❑Owner Given Reason for Denial <br /> IX,Conditions of A proval/Reasons for Disapproval <br /> qk�� E <br /> , �I* 126 ID <br /> Attach to complete plans for the system and submit to the County anty on paper not less than S iR in siye, <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08114) <br />