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,^Y;.*:x`t'�'',�,` County, <br /> 'r_'- '+:;.4 IndustryServices Division '--"-h ' <br /> F. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ,mot y.,. •;:; '. �. <br /> � P.O. Box 7162 <br /> :iS r�, $&t -23- 4.7 <br /> „ _- _._, Madison, WI 53707-7162 ��� <br /> State Transaction Number <br /> Sanitary Petiint Application <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 Servies. Personal information you provide may be used for secondary i,Z 8�I <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. w, rl o f f t i( /?, <br /> I. Application Information-Please Print All Information 'J <br /> Property Owner's Name Parcel# <br /> v7-ga(y-A-3�J- /Y-Di-S OS- 007 <br /> Je W <br /> a1c re o+A -o/ii'oo <br /> Property Owner's Mailing Address Property Location ,,It 6 4 SO <br /> 3(pii Se QV A Crt Govt.Lot 7 <br /> 1Ci/ty,State // Zip Code Phone Number y, 'A, Section 3 <br /> �/G �YlG.1S �5ht__ M� 5757d 7 cucleone <br /> IL Type of Building(check all that apply) Lot# T 31 N; R E or <br /> 121 I or 2 Family Dwelling-Number of Bedrooms 2 3 Subdivision Name , <br /> Block# <br /> 0 Public/Commercial-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use <br /> I/- it ? P)69 ® Town of /?ks k <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System Replacement System <br /> y � p y 0 Treatment/Holding Tank Replacement Only ❑ Other Iv[oditication to Existing System(explain) <br /> B• 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 15 q 3/ <br /> IV.i'ype of POWTS,System/Component/Device: (Check all that apply) <br /> ❑Non Press zed In-Ground 0 Pressurized In-Ground 0 At-Grade KN[ound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Efoldin Tarilc 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V Dispersal/Treatment Area Information: <br /> DesigifF16*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 1/SO Z9 YSa �a� 97. 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o-o <br /> New Tanks Existing Tanks o y a <br /> c.U cn w cn i.,-.C7 0- <br /> Septic or Holding Tank /G U a O o0 <br /> Dosing Chamber.. SW S.bO ���� <br /> • <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. _ <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> a /ct•, , /ZA,,,. / lots--ri 7is= 6('' <br /> Plumber's Address(Street,City,State,Zip Code) <br /> I77004 3-5--- Lti-ram /e" w`.5 ,'S'3 <br /> VIII.County t epartment Use Only <br /> Approved ❑ Disapproved Permit Fee G� Date Issued Issu• g e. -nt S'Dna e _‘gr . <br /> 0 Owner Given Reason for Denial S 11 5// �✓2 <br /> • <br /> IX.Conditions of Approval/Reas ns for Disapproval 9' E( E E meek.-• aii se- t 6-14c. rerpefre.413 <br /> MAY 1 0 2023 <br /> juj <br /> Attach to complete plans for the system and submit to the County only on paper oat less than 8 1/2 a 11 iac�es in si <br /> Burnett County <br /> Land Services Department C <br /> SBD-6398(R0313) 5-03 Sii �7 <br />