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Department of Safety County/ <br /> ...i. <br /> 0 & Professional Services, k��i� <br /> S Sanitary Perm Number to be filled in by Co.) <br /> PS Industry Services Division '5Jl - - .25 <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 n ding address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary c it <br /> purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats. rh <br /> I.Application Inform tion-Please Print All Information 2832 N <br /> Property Owner's Na e Parcel# <br /> Q9bc(8 t 67-6rz-e--q6-15-09 /s-G 5'-/laocL _ <br /> Property Owner's ail.ng AdAdress /� Property Location --ray \r):-SZ 01 <br /> / - 3 Lys- ( /d e: <br /> Govt.Lot <br /> Ci ,Staavy)te Zip Code Phone Number S-St7� �/ /'25'- 770/ C e '/a, Szi /a, Section <br /> II.Type of Building(check all that apply) Lot# T w N R 1S E or© <br /> , Subdivision Name <br /> Jar 2 Family Dwelling-Number of Bedrooms a(J�/ <br /> Block# <br /> 0 Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use __ CSM Number ❑Village of <br /> 2-Town of ->O450✓7 <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. Iew System ❑Replacement System Other Modification to Existing System(explain) ❑Additional Pretreatment I h it(exnlain) <br /> — <br /> B' ❑Holding Tank In-Ground ❑At-Grade 0 Mound ❑Individual Site Design DOther Type(explain) <br /> (conventional) <br /> List Previous Permit Number and Date Issued <br /> C. Oenewal Before ❑Revision Change of Plumber ❑transfer to New Owner <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design(gpd) Design Soil Application Rate(gpd st) Dispersal (s� Dispersal Area Pro osed(sf) System E q/ <br /> 3 (Qv/ /(e <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units 0 U h •- <br /> New Tanks Existing Tanks 0 o 2 it <br /> a U 'OS H to w (7 P. <br /> Septic or Holding Tank 144. , /D tQo / <br /> Dosing Chamber �c _ _ <br /> V.Responsibility Statement-I,the undersigned,ass e resp' .ibility for installation of the POWTS shown on the attached plans. <br /> Plum is Name rint) / Plum -r Sig . e MP/MPRS Number Business Phone Number <br /> c>r7 �1 (i) R,33 5' )/S"7P/ y?7 8 <br /> Plumber'd Address(Street,City,State,Zip Code) <br /> z 1f�47 R. W 3s 5; ei,, (,),- Tvs7z <br /> VI.County/Department Use Only <br /> 14 <br /> Approved 0 Disapproved Permit Fee Date Issued Issuin Agent <br /> Signature <br /> ❑Owner Given Reason for Denial S /12 F J 1123 IZOM <br /> Conditions of Approval/Reasons for Disapproval <br /> YVIR Dill sei-bac,k-S E C IE 0 <br /> -FD <br /> • <br /> strait re ( -+ J1 W <br /> �j�lOw q,<< �,n�y and � �,i yy�i-f-i n7 �'kY p� �o <br /> 3 4 s+%turkl-it'' i5 fevm•red Iztfr _.ii i i FEB 23 2024 <br /> 1" L� <br /> ui <br /> s �}e,9rl. SkiS-It'n -e I n/Q.140A 4b 6e �'(P-D-Ff- Dr vt�5 G,,e r- <br /> Burnett County <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inchrall sigerviiees Department <br /> SBD-6398(R.03/22) `y I �aZS #55(0 5 <br />