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/��" °i ems. Industry Services Division County �/ <br /> ,-t t\, 1400 E Washington Ave U/lx,• . '' P.O.Box 7162 <br /> (sl • p Sanitary Permit Number(to be filled in by Co.) <br /> e`er,+ Z Madison,WI53707-7162 5AN•-23 - (4- <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.1(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary pennit 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 maybe used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),.Stats. r I2 l I i <br /> I. Application Information-Please Print All Information )GX'y ✓ <br /> Property Owner's Name Parcel# <br /> 14 <br /> d nut "7-0 -z404-70102-049-0/ <br /> Property Owner's Mailing Address / / Property Location <br /> Z 76V0 64 6 rCJ£� Govt.Lot <br /> City,State Zip Code Phone Number i%, ki, Section Z U <br /> .WeiP4er i,_f'l` 51/b1,3 circle one) <br /> T 7 0 N; R /6 E ore <br /> II.Type of Building(check all that apply) Lot# <br /> Si I or 2 Family Dwelling-Number of Bedrooms q Z. Subdivision Name <br /> Block <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> vzi nQr QWTown of OA) 44 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. by New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> $• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ty Non-Pressurized In-Ground 0 Pressurized In-Ground 0 AI-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.DispersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> icY) <br /> 120d <br /> VI.Tank Info Capacity in Total #of - Manufacturer <br /> Gallons Gallons Units a <br /> New Tanks Existing Tanks ' v$ ;, `- y_gm ,3 <br /> c,U iii vt, m is 0 ta. <br /> Septic or Holding Tank /Z 50 /Z�j U I Ij../5i( <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumer's Name(Print) Plumber's Si MP/MPRS Number Business Phone Number <br /> ka M f / g -I952/ 76--.5-g-o2o-z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> g8( %v 14 t k 4/ +Jeb /- r LA 54/ 9 3 <br /> VIII.County/Department Use Only <br /> Permit Fee Date Issued g t si <br /> Approved 0 Disapproved fifi <br /> s ° <br /> � <br /> 0 Owner Given Reason for Denial `���J 5/1 l/23 Jl y✓�l 1 / <br /> IX.Conditions of Approve ons for Disapproval <br /> rkiCe4-- al( 5ef#ic a 46 5 tt,.k er► - _�� <br /> • <br /> • <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x I i inches MAY 1 9 2023 t�� <br /> Burnett County LJ <br /> Land Services Department <br /> SBD-6398(R.08/14) $j j 2 c{1 E I?-6 30 <br />