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}�;;, ,:;,4-:w - County <br /> �...'<-. Indust Services Division LA rr% e <br /> j F: i#.Z A._ 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> � ) P.O. Box7162 �A►�_ ) {off� . <br /> {�� 'j : , Madison, WI 53707-7162 (�" C <br /> -ti '^L'r4si v.77 <br /> oG ✓V <br /> State Transaction Number <br /> Sanitary Pet'nit Application . <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> iss 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 0-7_Git 8_,1.ye,-/y -03—S--/.S",c0s <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information I\ C "vie <br /> Property Owner's Name Parcel# <br /> MOI eti �NL///eve 212.14 kCr POiLit/ <br /> Property Owner's Mailing Address Property Location <br /> N3S8o 67A, .t- <br /> Govt.Lot <br /> City,State Zip Code Phone Number IA, %, Section 3 <br /> Ea.s(. o r-(i'1 ,5-1f 61/ e (circle one),., <br /> N; R nt E or ift <br /> II.Type of Building(check all that apply) Lot# <br /> V 1 or2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number p Village of <br /> ❑State Owned-Describe Use <br /> IF Town of .SCO 7,1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> pNew System ❑Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. Permit Renewal ❑Permit Revision List Previous Permit Number and Date Issued <br /> ❑ Change o f Plumber ❑Permit Transfer to New <br /> Before Expiration Owner - <br /> IV..Cypeof POINTS System/Component/Device: (Check all that apply) <br /> P NouVi st sized In-Ground 0 Pressurized In-Ground ❑ At Grade ❑ Mound 24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> 0%Hdldifig,Tatik 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V-Dispersal/Treatment Area Information: <br /> Design-Fla(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> // r , '7 d 17 at,2s. 9 0. ° . <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units E -, ca <br /> New Tanks Existing Tanks 0 (; u c� `5 <br /> o <br /> o,U En ti in u=U a. <br /> Septic or Holding Tank Jt 0 S3l.e, / /A P 5.(7/ ✓rI IC <br /> Dosing Chamber.. 7 i }, <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /Z/ /G 0 4/k /�--Gi .,� /4>i7, ei :8-57 7 rs= ,f 6 6-11/5 7 <br /> Plumber's Address(S et,City,State,Zip Code) <br /> ,1776 D f/1,•7 3'.s— w-e.SS/ri ti-7--- 5 F5 ' <br /> VIII.County/Department Use Only <br /> Permit Fee ot9 Date Issued I in A t Si azure <br /> Approved ❑ Disapproved $ g <br /> ❑ Owner Given Reason for Denial lit JI l <br /> IX.Conditions of Approval/Reasons for Disapproval O/� ‘ 3 ^ v i <br /> ✓y1K51- -fined- 3 5 e,r�fi Ci by n t ftryf' «Vv" <br /> all 6 -t 5-E-4. 7.:/le-igelli5MAY �1 8 2023 , . <br /> 1Z <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/?s 11 ii ches in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R0313) <br />