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,mil%""''"�,, Industry Services Division County <br /> :, �;�',, 4822 Madison Yards Way �`S i� <br /> PE N. g0i I_' Madison,WI 53705 itar'Permit Number(to be filled in by Co.) . <br /> ;, , P.O.Box 7162 �3 "®� jo�il � <br /> '`' Madison,WI 53707-7162 <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(it ottrerent man matting address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary 2 6 )..D. 'f <br /> purposes m accordance with the Privacy Law,s. 15.04(1)(m),Slats. <br /> L Application Information-Please Print All Information (F - 4t ,q a 2� <br /> Property Owner's Name Parcel# Y <br /> / <br /> ti A iS1�!l� ��l S7 `. , is S do , i - . ' - '. 13% /: % - ) Or9i <br /> Property Owner's Mailing Address Property Location 41,4.4 O L 4' l o tt 0/ <br /> 2 I,_)) � C4 } /Y/G ljT7X / Govt.Lot <br /> City,,ate Zip Code Phone Number <br /> // /lA/ ✓ V. ''A, Section , -) <br /> II.Type of Build (check an that apply) Lot# T , ) . N R // E o f <br /> Ell or 2 Family Dwelling-Number ofBedrooms '/ Subdivision Name <br /> jPublic/Commercial-Describe Use Block# , V6' 1�"^'Y' Z S te' <br /> City of <br /> ❑State Owned-Describe Use CSM Number ■ illage of <br /> l rown of 2(/ <br /> III.Type of POINTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C i <br /> applicable.) <br /> A' []New System replacement System pother Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> a ❑Holding Tank In-Ground at-Grade Mound 0Individual Site DesignOther Type(explain) <br /> Ella-Ground <br /> (conventional) <br /> C. ❑Renewal Before ORevision °Change of Plumber [ lTransfer to New OwnerList Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersalffreatment Area and Tank Information: ..- <br /> • <br /> Design Flow(gpd) Design Soil Application Rate(gpolsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> l C i /g- . 3%s) ",5°_,7�77., <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units -7J24 -'r 5 - p,-/ - .s:, ;, V v y <br /> Ncw Tanks Existing Tanks ' lbk `Le*) o _ .o A CO <br /> 0 <br /> . <br /> Septic or Holding Tank .. <br /> Dosing Chamber gar) <br /> eG C% I II 1 R I I t - <br /> V.Responsibility Statement-I,the undersigned,assume responsi . for installation of the POWTS shown on the attached plans. <br /> Plum ' Name/Print)i Plumber's S -/ / MP/MPRS Number Business Phone Number <br /> PI is Address Sttroe Ci S Zipi17` <br /> ( t, ty fate, C ) <br /> •_ Co ,tee i /d r • :-_-,77.. <br /> VI.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee <br /> Date Issued Issuing gent Si e <br /> 0 Owner Given Reason for DenialL'�13 3i; g 123 , <br /> Conditions of Approval/Reasons for Disapproval <br /> 0 Me-el- all 5e1-b4&-F s e Iett ell- 927_3 Li.2 - <br /> r242023 <br /> ----L) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t2 x I1 inches in irse <br /> Burnett County <br /> SBD-6398(R.03/21) <br /> Land Services Department <br />