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�.atirna_ui <br /> Industry Services Division County <br /> 1400 E Washington Ave <br /> P.O.Box 7162 <br /> Madison,WI 5370'1 7162 San Permit Number to be filled in by Co.) <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this forrtr 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 /> putposes in accordance with the Privacy Law,S.15.04(I)(m),Slats. <br /> I. Application Information-PIease Print All Information <br /> Property Owner's Name Parcel# <br /> a V 7V6 tD <br /> Property Owner's Mailing Address Property Location <br /> -/X� 09 /'v Govt.L/o�t <br /> City,State I ,t Zip Code Phone Number /V A y, �� y,, Section 7 <br /> G/VI"I r 1(�1 V t T N. R ctrcle onol <br /> II.Type of Building(check all that apply) Lot'r <br /> � �E <br /> �I or 2 Family Dwelling-Number of Bedrooms Subdivision Name ROV <br /> Block g <br /> ❑Public/Commercial-Describe Use Q City of <br /> ❑State Owned-Describe Use CSM Number ,❑��/!Village of <br /> l7'Town of_ /Z Wi� <br /> Ili.Type of Permit: (Check only one box on Hne A. Complete line B If applicable) <br /> A. <br /> ❑New System ❑ Replacement System E�Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Number ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Onmer l 2 5 12 f l I an cl <br /> W.Type of POWTS S stem/Cora onent/Device: Check all that apply) <br /> I <br /> ❑Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Hording Tonk ❑Other Dispersal Component(explain) C Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(s0 Dispersal Area Proposed(sf) System Elevation <br /> 3oD <br /> VI.Tank Info Capacity in Total of Manufacturer <br /> Gallons Gallons Units U p y y <br /> New Tanks Existing Tanks S �, CJv v <br /> a U in' K rn t:t7 a <br /> Septic or Holding Tank Sao <br /> Dosing Chamber V "V <br /> VII.Responsibility Statement-I,the undersigned,assuzWKesponsibillty for iastallation of the POWTS shown on the attached plans. <br /> Plu cr's N�0"";A"Uf/ <br /> (Print) Plumber' Si aturc MP/MPRS Number Business Phone Number <br /> Plumhrr's Address(Street,City,State,Zip Code) <br /> Gbtf f /J`VOAW ll� �� t�leb��er- t�ls• 5�I 9 <br /> VIII.County/ e artment Use Only <br /> Approved Disapproved <br /> Permit Fee Date issued Issuing Agent Signature <br /> ❑ ep ,Z /����� . <br /> ❑Owner Given Reason for Denial S 3 76 <br /> IX.Conditions of Approval/Reasons for Disapproval )�5— <br /> uk'ls�lYlo 4an � C C� L� ��I <br /> X i S-1�nn S �k G �Gler� Spi l �o r� ,inn _ ��: .�w <br /> Attach to complete plans for the system and submit to the County anry on paper not less than S 112 z 1 t inches in sin DEC „� <br /> UiU <br /> Burnett County <br /> SBD-6398(R 09114) Land Services Department <br />