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N <br /> ;., :; 41%, County <br /> 7471 ''+-„. Industry Services Division /,3U✓'n-v'# <br /> . ` L. f' 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ,' ,S :, , rl P.O. Box 7162 n�` .�3—L.° <br /> 4,, Madison, WI 53707-7162 <br /> State Transaction Number <br /> Sanitary Pet nut 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 370 N <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. / <br /> I. Application Information-Please Print All Information f i'h lkli' .,fH 7r/' <br /> - Property Owner's Name Parcel U# <br /> U? 0 <br /> -j,.'`1013-36-SOS- va!- <br /> Eu i-evrt^ Zappe, Cid oa0 <br /> Property Owner's Mailing Address Property Location tale a 6.09/ <br /> l4 / 6 r Do n r 2 , t UVc y Govt.Lot <br /> City,State Zip Code Phone Number y, %, Section 3 6 <br /> L/ (circle one) <br /> /1wG�So✓t GVT �yd� �0 T t1r0 N; R /S Eor0 <br /> II.Type of Building(check all that apply) 1 Lot# <br /> g I or2 Family Dwelling-Number of Bedrooms o` Subdivision Name <br /> Block# <br /> • <br /> ❑Public/Conunercial-Describe Use • <br /> ❑ City of <br /> ❑State Owned-Describe Use CSN[Number ❑ Village of <br /> .® Town of Jar,l4ilk, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) • <br /> A. <br /> ❑New System X Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner I N v <br /> r- . <br /> IV.Lype,of POWTS.System/Component/Device: (Check all that apply) <br /> ❑Non Pies razed In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> "E{gldm=Tank 0 Other Dispersal Component(explain) ❑Pretreatment,Device(explain) <br /> V.Dispersal/Treatment Area Information: ' <br /> Design:TIN,(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 3 0 d — _ <br /> • <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units -4 B o 7 <br /> New Tanks Existing Tanks o v ci 2 . <br /> ,U 65 in wU a. <br /> Septic or Holding Tank 44s-6/75"0 ,,4O OV / (y/e S ti--- X <br /> Dosing Chamber_ ) -}, <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prinnt)f Plumber's Signature MP/MPRS Number Business Phone Number <br /> /2/c-f /`/0, /6ir ; / 7- n-7� .0.4SefS/ 7(.5 � o y/S-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.County/Department Use Only ,-� <br /> Approved ❑ Disapproved Permit Fee D�at Issued Issuing gent Signature <br /> ❑ Owner Given Reason for Denial $ ��6� G`��iIV3 <br /> ...".) <br /> IX.Conditions of Approval/Reasons for Disapproval � r -. <br /> . <br /> -III.+ au e,-4-PS and -Eon-e re�u� ' � � � v <br /> E Th <br /> j + <br /> - -fie cor ones+ PILA, veiS i mS culd, du-ItS <br /> I, MAY 1 0 2023 jj <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 tax ll i ehes in,size <br /> Burnett County <br /> ! `.and Services Department <br /> SBD-639S(Rmill CiC--72972 $17� <br />