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�.+ '�!►i County <br /> / All ndustry Services Division Burnett <br /> � i; ® '�� t% ' ED' <br /> 1400 E WBShington Ave SanitaryPermit Number to be filled in Co. <br /> '` _ i�I '. P.O. Box 7162 ( ) <br /> Vfi. Pa �fi� Madison,WI 53707-7162 °� (zN <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 Servies. Personal information you provide may be used for secondary 1481 Hamms Rd. <br /> purposes in accordance with the PrivacyLaw,s.15. 1 m,Stars. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# GUL <br /> James Church nct=k11aA 028411101300 / 7F f <br /> Property Owner's Mailing Address Not Property Location <br /> 2316 Cheryl Dr. Govt.Lot <br /> City,State Zip Code Phone Number SW %, NE /,, Section 11 <br /> Jacksonville FL 32217 (circle one) <br /> H.,,Type of Building(check all that apply) Lot# T 40 N; R 14 E or W <br /> C7 1 or 2 Family Dwelling-Number of Bedrooms 4 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Vil age of <br /> Town of Scott <br /> III.Type oJ Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A' New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑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 /> I,``VT a of POWTS System/Component/Device: Check all that apply) <br /> L/Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> l Y727 1.7 1,. 2/ .2.Z0 193.0 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks c !�5, $�' <br /> C`L U rn Fn Can k. <br /> Septic or Holding Tank 7 S Q X <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume Wsponsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si a MP/MPRS Number Business Phone Number <br /> Rick Brown 231251 419-0739 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 637 Spooner WI 54868 <br /> Vill.Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued issuingAg t Sign r <br /> ❑Owner Given Reason for Denial $_375'e— <br /> IX.Conditlo s of Approval/Rea s for Disapproval <br /> S( `; <br /> E EBYI <br /> Attach to complete plans for the system and submit to the County only on paper not less then 8 1/2 x 11 inch m si e <br /> MAY 2 5 2022 <br /> SBD-6398(R0313) <br /> Burnett County <br /> Land Services Department <br />