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E`2�p r.ant,,.r, County <br /> afety and Buildings Division <br /> y 1�y#< 0 p .Washington Ave.;P.O.Box 7162 <br /> • �.P_' , K g Sanitary Permit umber(to be flied in by Co.) <br /> S' Madison,WI 53707-7162 Sanitary <br /> - _ �f� <br /> a (� `37‘42-- <br /> Sanitary Permit Application StfattcTransactiionNumbeerr z <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit v 7�/ 0/V 3 — <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 Servies. 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 All Information <br /> Property Owner's Name Parcel# <br /> 3 i0 u 1 o> t.z.„4 fi 4 z3L7.� <br /> Property Owner's Mailing Addressl �/ Property Location <br /> c/L'7/ /`�rO-- C' Govt.Lot _ <br /> City,State l 11/ /, / Zip Code - Phone Number A/ y., •$F y,, Section�1 <br /> f t, .BL a 7�}. Lt/l y /b/11 T.2 7 N. R /7-1.".0 <br /> E.Type of Building,fcXieck all that apply) Lot# l <br /> ,2 Family Dwellingng <br /> -Number of Bedrooms_ :inbdi:;;ion Name <br /> B lock# .----- <br /> 0 Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned--Describe Use CSM Number ID Village of <br /> 14 Town ofrl 7j.L`j`J <br /> III.Type tof Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' IVew System 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 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 Owner <br /> IV.Type of POWTS System/Component/Device: (_Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground 76LAt-(irade ❑Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑Bolding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) _ <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Atea Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> >°. .3 P17-0 7ZrJ _/�,I} <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a ° t'g Q <br /> New Tanks Existing Tanks . o E m A <br /> Septic or Holding Tank 7"%S.,,., 7 4Les2—/ / <br /> " 4,_ <br /> Dosing Chamber --3 j 7) / I�-e) <br /> VI(.Responsibility Statement- I,the undersigne,`� ,.e responsibility for installation of the POWTS shown on the attached plans. <br /> Plat mbet's Name(Print) PI... , Signature MP/MPRS Number Business Phone Number <br /> 9 <br /> .---)A-C.1..1/4_,./ .7767tic?/1 7..)- 471'7,6/ <br /> Plumber's Address(Str City, fate,Zip .d- <br /> ,//9 -7 " /(.20Ve . S7 - 11-j Z (AV ('( -c: (')') 7 <br /> VIII.County/Department Use Only <br /> Approved I ❑ Disapproved Permit Fee Dateat Issued in g Signatur ' - J <br /> 0 Owner Given Reason for Denial $37,• i 8.7 Z/ / �/ <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> //1►0i,�-.--13yci i $3- --- <br /> . . . V l5 <br /> Attach to complete plans for the system and submit to the County only on paper not less ta II inches in size <br /> JUL 2n 2021 <br /> SBD-6398(R. 11/11) <br /> Burnett County <br /> Land Services Department <br />