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Industry Services Division County t� <br /> 1400 E Washington Ave <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707 7162 lL 15 <br /> L,: L_. aI <br /> Sanitary Pernut Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this farm 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 Law,s.15.04(1)(m),Stats. U ,� <br /> I. Application Information—Please Print All Information 7 7reA,6uw— <br /> Property Owner's Name Parcel# <br /> 4kel ' <br /> d -a?-Z• - 2- /6-7-0- <br /> Property Owner's Mailing Address V <br /> pp,�� �l Property Location -9 87�5 <br /> �5// 7&,t/ "7 Govt.Lot CJ <br /> city,state Zip Code Phone Number ,�� Y,, Section 12 <br /> �rO N, R�E ot- <br /> le on <br /> II.Type of Building(check all that <br /> '!that apply) � Lot# �� • <br /> I or 2 Family Dwelling-Number of Bedrooms 'Suubbrdivision Name <br /> Blockg //*,c,XG Icy IeWk VV <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CS Number ❑Village of �p _ <br /> Oi Trntinof_ VQC rjbl� <br /> III.Type of Permit: (Check only one box on line A- Complete line B If applicable) <br /> A. ❑New System Replacement System <br /> Y � ep ys ❑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 Onvner <br /> W.Type of POWTS System/Component/Device: Check all that apply) <br /> 1 V <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank C3 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersallTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> y5-0 6yl <br /> VI.Tank Info Capacity in Total n of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanis <br /> c.U in K rn i.L v o. <br /> Scptic or Holding Tank- <br /> Dosing Chamber �W <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown.on the attached plans. <br /> Plu cr's Name(Print) Plumber's Signature �_ MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> iOM AVOIAW IA ;90/ (1\Je6t;Y4r vi- 5ZIB19 3 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Feee- _ Date Issued in t Si <br /> ❑Owner Given Reason for Denial 5 _? FI q 1,2 3 <br /> IX.Conditions of Appr val/--RII easons for Disapproval <br /> soils Grve r )f 11qn <br /> a o0 <br /> I <br /> Attach to complete plans for the system and submit to the County anly an paper not less than 8112 x 11 Inches ikki'W '' � ,LULJ <br /> q 5 9 <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R 08114) <br />