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Industry Services Division County <br /> 4822 Madison Yards Way Burnett <br /> `ira - Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> $ P.O.Box 7302 SA(v..,22-1i/ <br /> Madison,WI 53707 L�1(p gg� <br /> r-a2, -111-r <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 Bass Lake Lane QI <br /> _ <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m).Stats.I.Application Information-Please Print All Information 04( `Jl/ 3 b <br /> Property Owner's Name Parcel# <br /> Greg Phillips 070242391424204000011100 <br /> Property Owner's Mailing Address Property Location <br /> 9640 State Rd 19 Govt.Lot <br /> City,State Zip Code Phone Number <br /> Mazomanie WI 53560 SE ,,,NW v., Section 24 <br /> II.Type of Building(check all that apply) Lot# T 39 N R 14 E or W <br /> El or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ['city of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> V 21 P203 EiTown of Rusk <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. <br /> ✓❑New System Replacement System ather Modification to Existing System(explain) DAdditional Pretreatment Unit(explain) <br /> B. ❑Holding Tank Oln-Ground EAt-Grade Mound 0Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ElRenewal Before ❑Revision ❑Change of Plumber ['Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.DispersallTreatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 .7 642.8 646 89-94 <br /> Capacity in Total #of Manufacturer <br /> ,) <br /> Gallons Gallons Units u o 0 <br /> Tank Information 0 <br /> New Tanks Existing Tanks u c v 2 Ti re ca <br /> a. U in . . is. (. P. <br /> Septic or Holding Tank 1000 1000 1 Wieser ✓ I I—"I lii u I I <br /> Dosing Chamber I I I I ❑ ❑ <br /> V.Responsibility Statement-I,the undersigned,assume respo bill f installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign e MP/MPRS Number Business Phone Number <br /> Dan Burch 253808 715.416.1642 <br /> Plumber's Address(Street,City,State,Zip Code) I <br /> N5921 County Hwy K Spooner WI 54801 <br /> VI.County/Department Use Only <br /> Permit Fee p Date Issued Is g Age Signature <br /> Approved El Disapproved <br /> E] $�� ����Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Di approv 1 t✓ a Pd <br /> I/1'1ee�- F s ec 1" <br /> • <br /> IECEOVEDI, <br /> 9v} 4065,0 <br /> AUU 0 8 2022 <br /> _ u <br /> Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x II nches it size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.02/22) <br />