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f/—�s,1 Industry Services Division County J <br /> , p ': . 1400 E Washington Ave �VrNG1 � <br /> / <br /> 1`1 - Sr ; : P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> • Madison,WI 53707-7162 <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 Ad�(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary I A� y U l/915 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. <br /> I. Application Information—Please Print All Information {OCrld,' pG/CB fIr4. <br /> Property Owner's Name Parcel <br /> /%�•9(reo Illeye7 o76Y8-L-3 -16.2e-/ 0/-e0e-ouoo0 <br /> Property Owner's Mailing Address Property Location <br /> trJ z q7 4e/rA1/J/e Govt.Lot <br /> City,State Zip Code Phone Number li b <br /> IW� /. %, %., Section <br /> Yr �t �J_ �� - T �, N: R AP(circle on <br /> II.Type of Building(check all that apply) Lot# E or <br /> / <br /> Cir1 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 /> Iji Town of Mee/vr'jA-/ <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> a New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> 8. 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 !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(glad) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> y5'U l D y 56 P60 97. -2- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units " c <br /> New Tanks Existing Tanks ea U L <br /> ei o 9. 2 u s a <br /> /� a U •c ro ix.a a. <br /> Septic or Holding Tank /V oV !)''�j (/{ f <br /> Dosing Chamber 00 �1 , , <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu er's Name(Print) i Plumber' ignatrtre MP/MPRS Number Business Phone Number <br /> or* T1�Q t( % 5795' <br /> Plumh�r's Address(Street,City,State,Zip Code) <br /> 8,d l /40,/iv t k 41 tJebe- Ve 51/69 3 <br /> VIII.County/Department Use Only <br /> gffApproved ❑Disapproved PermitF[ee Daate Issued Agent ' M <br /> D Owner Given Reason for Denial S L1�✓� t I���3 CAU. efGG _ �/ <br /> IX.Conditions of Approval/Reasons for Disapproval 1 _ <br /> 04- a(( s- (04/ / k ' r\i APR 2 8 2023 <br /> i <br /> Burnett County <br /> i nr1 Services Department <br /> Attach to complete plans for the system and submit to the County only on paper not less than S In s I1 In <br /> Ct( #: l 2 S 6 <br /> SBD-6398(R.08/14) <br />