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iir l,,-, County <br /> /ram ',_ Industry Services Division p .v'hlf <br /> ram= <br /> , r` ft,t l 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> —_ �)- P.O. Box 7162 l SPN1 / <br /> '' tjy. , Madison, WI 53707-7162 �T- l _ <br /> Sanitary Pei_mit 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 Servies. 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 <br /> Property Owner's Name _ ) oParcel ft J.-y _/S-_��. d O d -ro m v <br /> TOiv✓1 dl- J, J<son /-Iee /--pt �1 on1Oft' <br /> Property Owner's Mailingli3 Address Property Location Tax t D 33u22 <br /> 1 .Sg / Co Rol 7)- Govt.Lot <br /> City,State Zip Code Phone Number / %, Section of 7 <br /> 1,r4^,rg t ,� Sle8 circle one} <br /> W >T w� � 3 T ya N; R � E orb <br /> IL Type of Building(check all that apply) Lot# <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> / Block# • <br /> ,&,Public/Commercial-Describe Use t I eG - 4 • <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number p Village of <br /> g Town of Jo.a4sool <br /> :'i: <br /> III.Type of Permit: (Check drily one bor,•on line A. Complete line B if applicable) <br /> A' 0 New System iirReplacement System ❑Treatment'-folding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ 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 POWTS,System(ComponentfDevice: (Check all that apply) <br /> it-NalT;surized In-Ground 0 Pressurized In-Ground 0 At-Grade ❑ Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> z Utz% <br /> ( Ki[cmgTank ❑Other Dispersal Component(explain) 0 Pretreatment,Device(explain) <br /> V Dspe>ia1/Treatment Area Information: <br /> Des gn how(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer v , <br /> Gallons Gallons Units a r °7 1. <br /> U u (n <br /> New Tanks Existing Tanks la <br /> ` o a; 2 1° El <br /> / a,U m ti cn wU a <br /> Septic or Holding Tank 3 00a 3600 -- j v pe.5 ev <br /> Dosing Chamber- . • t '}i <br /> VII.Responsibility Statement-I the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> I 'c/c /yop kI h s /Z ,0 ,4 al)s-e-c/ %s= V 6-.-QLS`�? <br /> Plumber's Address(Street,City,State,Zip Code) <br /> k • <br /> 7 7 / { .3-5.-- vv...bs 71Y.v (Alf.— 17/t S 3 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date 1sssu d L/ Issuing AOg/ent,Signature _ <br /> ❑Owner Given Reason for Denial $��`� aD �l O l e � V�IK_ — <br /> IX.Conditions of Approval/Reasons for Disapproval E C E- <br /> Mfek OP sA- c- 5 <br /> rapt/6a u cbu r1+41 c Sic r?p I ff-vne4 ,, <br /> 4,l - Ilk � � �� MAR 13 2024. � <br /> d <br /> Attach to complete plans for the system and submit o the County only on paper not less than 5 t/Z x 1I inches ii size Burnett County <br /> Land Services Department <br /> at( -74155' ¢37' <br />