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- `III` \, _ --�'" Industry Services Division County Liefiem <br /> ` t 1400 E Washington Ave <br /> p Lp Sanitary Permit Number(to be filled in by Co.) <br /> 1,9:.`SiD <br /> P.O.Box 7162 <br /> \6 �_ Madison,WI 53707-7162 ,5�A _2 7-L u64l <br /> - Sanitary Permit Application State Transaction Number <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 Services.Personal information you provide may be used for secondary <br /> purposesp in accordance with the Privacy Law,s. 15.04(I)(m),Stars. �^?a/Cr ��'�•) T'r� <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name /�/ Parcel# <br /> robe. II?tres �.ot Installed cl742V- -40 goe-s'/s-otti-oz3000 <br /> Property Owner's Mailing Address /� Property Location <br /> eV� A/AN.)t+/�u1,4%4 Govt.Lot <br /> City,State Zip Code Phone Number , <br /> � 4U / MA) /�, /,, Section <br /> 5 f((/ i/ trcle one <br /> T ' U N; R �j Ee a <br /> II.Type of Building(check all that apply) Lot <br /> g I or 2 Family Dwelling-Number of Bedrooms Z— ant <br /> Subdivision <br /> e <br /> Block# 4 /4 4‘/eg//Ve? <br /> ❑Public/Commercial Describe Use 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of V�/ D�D� VTown of ©t914kiAi,/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. i. <br /> New System}' 0 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 <br /> I V.Type of POWTS System/Component/Device: (Check all that apply) <br /> (YNon-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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Ap lication Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 310 y2 y 43Z rya B75,3 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ' U -0New Tanks Existing Tanks ' �, <br /> 2a v 2 u 2 si ra <br /> a V in v is t7 a. <br /> Septic or Holding Tank (1/1/' />00 / L A� Y. <br /> Dosing Chamber (,t/(/ !7 7/f/f <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plun er's N.amme(Print) Plumber' aturc MP/MPRS Number Business Phone Number <br /> t <�?./�Q 1./ , Plumber' <br /> 851 9V/ 7/57-166°-624-Z <br /> Plumber's Address(Street,City,State,Zip Code)/ <br /> 6681 4v`1/e nI Ile 141 ( Jeb L1 t' 5/&9, <br /> VIII.Count Department Use Only <br /> 1 <br /> Approved 0 Disapproved 5J . <br /> Permit Fee op Date Issued Is in Ag t Sign <br /> 0 Owner Given Reason for Denial 3 I1l a P/ -? � . <br /> SRN' <br /> IX.Conditions of Approval/Reasons or Disapproval <br /> y i ee-I- a(I 5e,4404 ..:'"-------1© E 11 g n <br /> D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IP-z 11 in i I AYR 2 1 2022 I / <br /> J �? U V <br /> Burnett County <br /> SBD-6398(R.08/14) _00 Land Services Department <br /> 3.7,., <br />