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° " '� Industry Services Division County <br /> �; ,�\ 1400 E Washington Ave t/(A/ <br /> (}�,$p P.O.Box 71:62 f Sammy Permit N (to be fined in by Co.) <br /> f4 Madison,WI53707 7162 5 AN 2 3— e2 6 <br /> �.,;�,' C —23.23a �7 5q <br /> Sanitary Permit Application ate'Transaction nn' er <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 teens 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(I pi),Stars. <br /> I. Application Information—Please Print All Information 2 f/ !N C eel' _ <br /> Property Owner's Name Panel# i aX tD:36,;(02.3 <br /> ea. ,vc�><i?7(4 (t O 14 L o7-0ly-T-�y-iy-ef-z ez-coo.0llece, <br /> Property Owner'sProperty <br /> � m � le �e 4 _ ��I�atian <br /> l/ <br /> City,State �,�/� Zip Code Phone Number VS, y; sty q <br /> #M//ft�j tootoo /t'1/4i 6-Pao (earl;one <br /> II.Type of Building(check all that apply) Lot* T ��/ N: R /K E o <br /> a t or 2 Family Dwdling—Number of Bedrooms / 6 Subdivision Name <br /> Block# <br /> 0 Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> Goo U 3 0 Ole Town of 5� <br /> III.Type of Permit (Check only one box on line A. Complete Hue B if applicable) <br /> A. ❑New System 153.Replacement <br /> ap System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existingsyscetn(explain) <br /> B. 0 Permit Renewal 0 Permit Revision CIChange of Plumber 0 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 /> ®Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>_24 is of suitable soil 0 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) Disperse!Area Required(at) Dispersal Area Proposed(sf) System Elevation <br /> I/50 , .7 61 2 t;y ? e <br /> VI.Tank Info Capacity in Total #of 1Mianuf cturer <br /> Gallons Gallons Units A i g c, <br /> New Tanks Existing Tanks s ` B $ III <br /> � �J/ ,4/ k U rn 1 II t7 ii <br /> F <br /> Septic or Holding Tank /060 /060 -a- 7/4;//,- /CA V <br /> Dosing Chamber t <br /> VII.Responsibility Statement—I.the undersigned,assume responsibility for muslintion of the POWTS shown on the attached plans. <br /> Plume's Name(Print)1 Plnmb MP/MPRS Number Business Phan Number <br /> - KO9 SeitAdfi / , e61q62/ 7/T'fi(-0262 <br /> / <br /> Plumber's Address(Street,City,State,Zip Code) <br /> (S8I v h"J l/e A/r (Ve66>71er tits 511$93 <br /> VIII.County/Department Use Only <br /> XApproved 0 Disapproved Permit Fee Dar Issued ' Agmt Sire <br /> D Owner Given Reason for Denial s q2 5 I Z f 2 g 11013 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> /lee-F LW 1,i is . <br /> 05- <br /> see cacn-ty curl S-ia4 retuite r 6 JJ �rr0v��2 nn7n�`d� <br /> lncti f ft* ►nus+ W/kc4L►u � b f 11 t)2024/ 14x E u v E3 <br /> Attach to complete Ouster the system and submit to rite Canty only on paper not less than a iR s II kdM <br /> DEC 2 7 2023 ./ <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br />