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Industry Services Division County AtrA/09— <br /> ';t1s. :t• 1400 E Washington Ave <br /> l. `spy -' P.O.Box 7I62 Sanitary <br /> Permit Number(to be filled in by Co.) <br /> \ N. <br /> BAN-22 -2b3 j����}/� /oryis��?mac;• /��r-�- .^� 'V7kt <br /> C�J T --2G`2tt' <br /> Sanitary Permit ApplicationSta <br /> s 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(I)(m),Stats. <br /> I. Application Information-Please Print AU Information <br /> Property Owner's Name Parcel# <br /> AgAyi Yfri: 4/J o 11•1 I&op -Z b/-oov-a itwo <br /> Property Owner's Mailing Address <br /> �j Property Location <br /> I Z 3 rG" d Govt.Lot <br /> City,State -/)- Zip Code Phone Number 8 <br /> ( r4,J)1 , WI 5 k�yp '�' �+ Section <br /> ctrole o } <br /> IL Type of Buildi (check all that apply) �{ Lot T_ N; R / E dam' <br /> q.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 CSIvI Number 0 Village of ���� <br /> isr Town of eve <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System E7 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 1 ❑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 /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DispersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> qs0 /I 0Y6-0 ys0 9q.6- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks ei u u " <br /> C. - a a y <br /> O � U .f1� W <br /> _ a U in ., y ii-CD a <br /> Septic or Holding Tank /O DO <br /> Dosing Chamber 76-6 -/-7r) 2. f✓] .X . . <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's S� elf/ i MP/MPRS Number Business Phone Number <br /> a* MAdzi <br /> Plumhtnt's Address(Street,City,State,Zip Code) <br /> I8( ,vh' t 1e fed/ (ve i7re•- L.,./1- 5109 3 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit FeeDate Issued Issuin Signature <br /> ❑Owner Given Reason for Denial S LI(''Jee[ i of 3J 12 2 <br /> IX.Og Con� �q s ofpp�ova ns fw o`Disapprovai <br /> if <br /> • <br /> Attach to complete plans for the system and submit to the County only an paper not less than 8 to s II ht sin (�4 <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) <br />