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/,,t===" ;1 t industry Services Division County gut 11 <br /> ; 1400 E Washington Ave ,velT <br /> ?, P.O.Box 7162 <br /> (¢1 Sp Sanitary Permit Number(to be filled in by Co.) <br /> ' c• : $ Madison,WI53707 7162\- �RtJ-a3-�3"1 <br /> Sanitary Permit Application S'ate <br /> Number <br /> IIn accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> ���as <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(1)(m),Stats. ``/ �� <br /> I. Application Information-Please Print All Information 4'3 0 V) <br /> Property Owner's Name Parcel# <br /> I a r'y' Zee. AAfON F/?mi/y TrvO- o7-62o-2-1 -/b 26-5' c 'D6-O[z.= <br /> Property Owner's Mailing Addresi Property Location # 19/ <br /> ;Col fNNe cJe✓ ie Govt.Lot 6 <br /> City,State ' ���J Zip Code Phone Number y, y� Section 2 6 <br /> aAl h /f1N 6 Z / cmrcleone-) <br /> T �(JN; R I� Eo <br /> II.Type of Building(check all that apply) Lot# <br /> it I or 2 Family Dwelling-Number of Bedrooms 11 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use 0 City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of 1"'" / <br /> v3 n�� [ Town of Ott J- di <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' 0 New System <br /> y II Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner 03 SL( I <br /> 1 t _ <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> q Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-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.Dispersa)iTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> e 00 .7 857 87 7?r•8 B n. <br /> 13 <br /> Vl.Tank Info ' Capacity in Total I #of Manufacturer S. <br /> Gallons Gallons Units o 0 <br /> New Tanks Existing Tanis c v 1 .1 <br /> - <br /> et�jj �]]�� ayU in K en iZ 0 a. <br /> Septic or Holding Tank 5110 760 /2'Q Z +L'14.1)1(44 t7'r d- (,Vcp (' I <br /> Dosing Chamber 7 <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plot er's Name(Print) i Plumber's Sigma MP/MPRS Number Business Phone Number <br /> 4b4 <br /> ,•Of", S.4.- --ilf( i 86195-2/ <br /> Plumber's Address(Street,City,State,Zip Code)) ,. t } / /� <br /> 68114vvi ' f ( <br /> i/' f/ Veb We` 9ie' f <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued/ issuC�li t Si <br /> 0 Owner Given Reason for Denial SI)? g/8/1-3 i <br /> IX.Conditions of Approve ons fpr Disapproval <br /> M C �- .[I 5 e-H- c.cU +. s- 1-e ;re <br /> ver: so;is ntie 5 t k ,/ts '-c�1►- <br /> @ liECEnfEr <br /> 41)5R9to completeAttach omplete plans for the system and submit to the Countyaaly on paper not Icss than 8 tl2 s It taeh� �z�{6 0 42021 <br /> _ L <br /> L ii Li), <br /> Burnett County <br /> _ Land Services Department <br /> SBD-6398(R 08114) <br />