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- .r'r` j•\ _ County <br /> / .1 `;„+ IndustryServices Division l3�r'H t'I <br /> ram, +.�:.;<. �� <br /> 4�rf:.:9 ':'.: ;, t = 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ,. •. P.O. Box 7162 Sig i _, -t 33 <br /> ,4; r,K:, Madison, WI 53707-7162 <br /> State Transaction Number <br /> Sanitary Permit 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 19 b I' <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information GvG,;4e 7a; Irk' <br /> Property Owner's Name Parcel# <br /> oiFt�� .^� O?-V,1O,a-yo./,-a3-S/S-SS/ <br /> 'e✓'rO _ 0.13cao <br /> •Property Owner's Mailing Address Property Location <br /> 8-57 4 11 Dvt t'ki N /4v'e Govt.Lot <br /> City,State lJ Zip Code Phone Number y, /, Section <br /> $t Ai,,,( /11/V ,5-57/q ((,circle one <br /> II.Type of Building(check all that apply) Lot# T �� N; R /b E o <br /> R 1 or 2 Family Dwelling-Number of Bedrooms A 1 Subdivision Name <br /> Block# <br /> El Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> ® Town of Ca/cIsiNd <br /> III.Type of Permit: (Check only one bos on line A. Complete line B if applicable) <br /> A' ❑New System �Replacement System El TreatmentlHolding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..Type of POW'lT'S.System/Component/Device: (Check all that apply) <br /> �No`n P essunzed In-Ground El Pressurized In-Ground ❑ At-Grade El Mound>24 in.of suitable soil El Mound<24 in.of suitable soil <br /> ❑ FloldmtTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V DIspecsal/Treatment Area Information: <br /> DesiorfFla(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> ba . "7 yA9 113,)- _ c, 3.s • <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ti o "S <br /> New Tanks Existing Tanks o „ a Ti . 2 R cd <br /> e.,C. cn H fi r.;=.tD a. <br /> Septic or Holding Tank .7 3—d 7S`d / lit!/-es r X <br /> Dosing Chamber- ) •), <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> • <br /> Plumber's Name(Print) Plumber's <br /> sSSig�nattuuure / MP/MPRSI Number BusinessBu Phone <br /> Number <br /> i? /L Alo,Al N f /-G�'"`�"'a"(' /47e,'^- ),e��0.57 //S= i/�ila- 94-S-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> ) 774'0 /4..r '5 we-y c/r.- t.-j .5_9 ?5.? <br /> VIII.County/Department Use Only <br /> $Permit' Fee� Date Issued�p/�� ing A t Sigma <br /> a Approved ❑ Disapproved <br /> ❑ Owner Given Reason for Denial (• rd'S 6 1 an / <br /> IX.Conditions of Appcova] ors fj Disapproval <br /> A e a Li E 1 E V IE <br /> B/iig y 0 ' <br /> JUN172022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than E 1/2 a Itches in size 4 <br /> Burnett County <br /> Land Services Department <br /> - <br /> SBD-6398 (R0313) <br />