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Funty <br /> „4 Industry Services Division ►^Y}ep <br /> 41400 E Washin ton Ave9 t Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison, WI 53707-7162 <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 fonns for state-owned PO�VTS 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 /Y 117S_ <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. .41-11 44, <br /> I. Application Information—Please Print All Information /' <br /> Property Owner Name Parcel# p , <br /> -is- <br /> /Oki i 140Z/u IG ©7-01.A a'S+a -Is=/ <br /> 30.r�va <br /> Property Owner's Mailing Address / Property Location Qom, i 77 i <br /> /33 3 /3A Ss G/C JzOI' Govt.Lot <br /> City,State Zip Code Phone Number y, Y4, Section JO <br /> circle one <br /> I1.Type of Building(check all that apply) Lot# T y0 N; R E ot9 <br /> [1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number p Village of <br /> WTown of Jac <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other ivloditication to Existing System(explain) <br /> B. Pert <br /> Transfer to New List Previous Permit Number and Date Issued <br /> Permit Renewal ❑Permit Revision El Change of Plumber ❑Pe <br /> Before Expiration Owner <br /> IV.i e,of P0WTS.S stem/Corn onent/Device. (Check all that apply) <br /> Prees�irized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.ofsuitable soil ❑ Mound<24 in,ofsuitable soil <br /> ❑ ft6lcl ark ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V�Ds en.al/Treatment Area Information: <br /> Design-Flow(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 <br /> Gallons Gallons Units � B U <br /> New Tanks Existing Tanks o dim a <br /> a U cn � inn w C7 a <br /> SzpticorHoldngTank �71 <br /> Dosing Chamber- r j <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the POtiVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> R, <br /> Plumber's Address(Street,City,State,Zip Code) <br /> D 3 1v�/-eSS�'r� [•t• P7' ri 3 <br /> VIII.Cou' nfyMepartdient Use Only <br /> pp-oved ❑ Disapproved $ennit Fez Date Issued Is uin Age Signatur <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of ppra/ovRea ns for Disapproval <br /> rw�-a� � <br /> �7�a��yas <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/?s 1 I inches' size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398 (R0313) <br />