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'ram'�`' industry Services Division County,ter ,., .}._ <br /> ,j;0 :c-. 1400 B Washington Ave Q G f/ <br /> ( l .. 8p$ P.O.Box 7162 Sa• nitary tary Permit Number(to be filled in by Co.) <br /> t.y '. S j Madison,WI 53707-7162 SfYN-/13--55 <br /> 4t =si:.,, r1•-.23—542 0439 <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. 15.04(1)(m),Stats. <br /> I. Application Information—Please Print AU Information <br /> Property Owner's Name AI Parcel# <br /> 114117 A i4 l o7-0/e-z-3y-f6-31-,o3-000-o11aao <br /> Property Owner's Mailing Address Property Location l <br /> zitefe aaK i IV 3v4- <br /> Govt.Lot <br /> City,State / Zip Code Phone Number V., V., Section 3Z <br /> GJ;i eAl W; Jam g 7 Z circle oae 7 <br /> II.Type of Building(check all that a FFY)l '2— Lot - T 3 N: R / E <br /> Pi I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> 121 Town of CII8t W,-' <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. p New System Y g Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Cha�e 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 14 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.DispersallTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 t • 0 300 3e0. 91 .9 <br /> VI.Tank Info I Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> a` U q <br /> U ini An Li a <br /> Septic or Holding Tank Y <br /> Dosing Chamber `-�ty6 -}� i A /VII.Responsibility Statem✓✓e"n�tt--I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name� (Print)// Plumber's • tut MP/MPRS Number Business Phone Number <br /> Ay <br /> or-m /pl/Q 4/ k�� eV 62/ 7/5"-•S -!32o2 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 41_ ,81 Writ/ i le '4t �Jeb , GA- 5'f(9 3 <br /> VIII.County/Department Use Only <br /> Permit Fee - <br /> Approved 0 Disapproved $ <br /> LI �� DateIssued � yirm t Sign <br /> ❑Owner Given Reason for Denial 5 )3 r/ <br /> .;14- e4.4 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> (rt ee ,U S c14S fs c re:e/�,,,•ttikt4 <br /> • --r) 1 g,c -E. v -E,11 <br /> Attach to complete plans for the system and submit to the County only on paper not less than S to x II imam I tte MAY 1 2 10L3 <br /> 1J) <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br /> 01126 atea ItIZSZ3 <br />