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j - � Industry Services Division County <br /> _' 1400 E Washington Ave ���� y� <br /> `�.r$ .. P.O.Box 7162 Sanitary PermitV Number(to belled in by Co.) <br /> J/ Madison,WI 53707-7162 <br /> CS7-2D- 113 <br /> Sanitary Permit Application State Transaction <br /> Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit WSW2 785 <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 /> SAI. Application Information-Please Print All Information <br /> Property Owner's Name <br /> Parcel# di l/0O <br /> G YCI)1+ A !I e gc,y1 Not Installed 0)-702o 2 L��r6 jq' .. ocG <br /> Prope Owner's Mailing Address 17.y. <br /> / i Property Location <br /> O$' <br /> 2�Z 7© �` 4 Q be c � I" � Govt.Lot II <br /> City,State ,Zip Code Phone Number sit/ <br /> ,� /ram ) ,,/ /+,�7 '/., N V/4, Section <br /> v v l� R 4 cv "V I .6 Li ? 7/��� i! role on <br /> II.Type of Building(check all that apply) Lot# 9o�y T (10 N; R .10 E o� <br /> 1 or 2 Family Dwelling—Number of Bedrooms Z Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number ❑lI Village of , <br /> V Z'Z ! y7 v stJ Town of o a KCa lid <br /> d <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) / <br /> A. <br /> pi New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision 0 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 ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil App ation Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units °' o <br /> i t ° <br /> New Tanks Existing Tanks ca ° U s, 4v� 4v� <br /> sue, O � N .D c6 CO <br /> Septic or Holding Tank ��/_V/ a C i ,m y rn w C7 a' <br /> Dosing Chamber T ��/ V// <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pl ber's Name r t) Plumber'Zre MP/MPRS Number Business Phone Number <br /> rot f 1ac� o bes�� a��'Jo 7 '7, 9e <br /> Plumber's Address(Street,City,State,Zip Code) Z ��s <br /> f�70o 3 � 2-o► � 4 o i r <br /> ��o w J SLI F� � <br /> VIll County/Departme t smy Approved ❑ Disapproved Permit Fee Dat Issu ssuin Agent Si lure <br /> 0 Owner Given Reason for Denial $ 2345 CO <br /> IX.Conditions of Approval/Reasons for Disap royal <br /> 36 avarc it -b ', kt41MCM i y. c k ��a� <br /> 41 U J( �tceV be Oft Dn &eId. , <br /> � C C� C� EMC --,1 <br /> I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x ll sin size <br /> JUN 1 9 2020 J <br /> SBD-6348(R.08/14) Burnett County <br /> Land Services Department <br />