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° '‘ Industry Services Division County /�U/N / <br /> 3 <, 1400 E Washington Ave <br /> !it.ti S! t,--, P.O.Box 7 i62 Sanitary Permit Number(to be filled in by Co.) <br /> !\ %, i,4,t; Madison,WI 53707 7162 5AN 23_ 2,1 66gb9 <br /> \�. i4.4 d'5`l- .3—l? 0✓ <br /> Sanitary Permit Application State Transaction l'innaber <br /> In accordance with SPS 38321(2),Via.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 /> purposes in accordance with the Privacy Lav�s.15.04(1)(m),Stars. Tux 1 A 35 g�{5 1(0 .1pt'AO t <br /> I. Application Information—Please Print All Information <br /> /07 �VD I► ki <br /> Property Owner's Name Parcel# <br /> f <br /> L/7d 7/74i detvc i Gl L o7-oiii-2-39-/y-o3- o5=4b7-ouzeo <br /> Property Owner's Mailing Address Property Location <br /> Z.19B0 I ZDf h y>L t.J Govt.Lot 7 <br /> City,State 4 <br /> �j� Zip Code Phone Number ,h, Y.,, Section 7 <br /> KO9C ' M#1i,uAr O Sv SD 6e' T N; R /Ci�rela E one <br /> or( <br /> II.Type of Building(cheek all that apply) Lot# <br /> / <br /> '9+I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block* <br /> ❑Public/Commercial-Describe the <br /> ❑State Owned-Describe Use C5M Number 0 Village of <br /> 0670 Vo/25 f26 ' �'To►vnof ,�sk- <br /> III.Type of Permit: (Check only one box on line A. Complete line B W applicable) <br /> A. i New System 0 Replacement ysSystem 0 Treatment/Holding Tank Replacement Only 0 Other Modification to ExistingSysten(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 /> 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 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device*plain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(si) Sys <br /> y50 . -7 6/0 6 yt; tem Elevation <br /> q 5. . <br /> VI.Tank Info 1 Capacity in Total *of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks a '' a <br /> Septic or Holding Tank /zoo WO / t,t e- `/ <br /> Dosing Chamber z <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWs shown on the attached plans. <br /> Plu cr's Name(Print) i Plumber's Signature MP/MPRS Number Business Phone Number <br /> Zeta <br /> KO* VrAdff e6195-1/ nc-fg-ozoz <br /> Stint,City,State, <br /> Plumber'stS8 ssf(,4t Z1 le67 ' €6� LA� Tf t31 3 <br /> VIIL f(CC��ounty/Department Use Only <br /> Approved ❑Disapproved Permit Fee J Date Issued <br /> 0 Owner Given Reason for Denial S�a'6 S� !0( IC1/�� ' r <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> I 2'I. 3• rt. <br /> -reek ,I t { 54 4C i K 0 C T 0 3 2023 il <br /> Atft r a►am eir the and subudt to the only on paper net ias theta in x II Lrela la <br /> �i� Cam' <br /> Burnett County <br /> Land Services Department <br /> fL 25 C,icl-#i 2ir45 <br /> SBD-6398(IL 08/14) <br />