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f3� \.� Industry Services Division County t 4 <br /> r;, a T�. 1400 E Washington Ave WA/di <br /> `��.�S�� ,', P.O.Box 7162 Sanitary Permit Ntttnber(to be filled in by Co.) <br /> ;I Madison,WI53707 7162 aYrl���J-L'�'4' <br /> %., gip,, <br /> mot,. ,.u.,. 23 -4 3 �d� 7 <br /> Sanitary Permit Application State TTransaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this font 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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stets. <br /> I. Application Information—PIease Print All Information <br /> Property Owner's Name �f ,�L Parcel# <br /> Property Owner's Mailing Address '/ Property Location 4 76-7 5 <br /> L1181 /key Tree)2Cl Govt.Lot /h� <br /> aCity,State / Zip Code Phone Number 1/4, 'A, Section /t) <br /> hey W.' T k0 5/t830 N; R / reiE <br /> U.Type of Building(check all that apply) Lot# <br /> Q4 I or 2 Family Dwelling—Number of Bedrooms Block 4 /7 Subdivision Name /-` 1.V,�,t"/ <br /> /1r{y Tre€,, l/6 <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> 3 Town of Teick50 ni <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> I <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issned <br /> Before Expiration Owner 2302 7 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> a Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade ❑Mound 24 in.of suitable soil Q Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 3� .1 yz1 yz ' TV i g /5 <br /> VI.Tank Info Capacity in Total 4 of Ivlanufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks u Vli •2 <br /> p ?i 2 ii 2 a r3 <br /> e.0 in A co it. O a <br /> Septic or Holding Tank /7 Il� 1 kr C..P `, <br /> Dosing Chamber GGii���� Y <br /> VII.Responsibility Statement—I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu er's Name(Print) / Plumber's Si MP/MPRS Number Business Phone Number <br /> T ��r v /a�� t�519 51/ 7//'--fg-62 <br /> Plumber's Addressdre(Street,re City,State,Zip Code),%/ i- ' /,, �z <br /> eo r /7', T'i nl Ile , f ( Jeh7�er- LA- 52f&9, <br /> VIII.County/Department Use Only _ <br /> a Approved 0 Disapproved Permit Fee Date Issued Issuing A r e <br /> ❑Owner Given Reason for Denial S L1 5 5 0II )-3 X/I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Meek ail s,63,, 5 f 5 , r .,ke +3 Ill 0IE0V1 I <br /> Need ti fl.-I c©mp. �nireMAY 0 y 7n73 i <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in s I1 inches V <br /> t Burnett County <br /> Land Services Department _ <br /> SBD-6398(R 08/14) 1" <br /> 4 5 C4,VAik <br /> .)I Z 61 q <br />