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Industry Services Division County <br /> 1400 E Washington Ave air <br /> P.O.Box 7152 <br /> -N '� !tr Madison,WI 53707=7162 Sanitary Permit Number(to be Sled in by ) <br /> . P-.q-r-..Q-3-1'R <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wit,Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application fames for state-owned POWTS are submitted to Pmject Address(if different than mailing address) <br /> the Department of Safety and ProfWonal Services.Personal khrrn nation you provide may be used for secondary <br /> Pumoses in accordance with the Privacy Law s.15.04 I m Stets. ' <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name parcel# <br /> 0,A,,e. <br /> Property Owner's Mailing Adders Property Location <br /> 273 9 9 �.v�en Gk��l Govr.Lot <br /> City,State <br /> � " r,,G/ zip Code PhoaeNumber y; Section 3� <br /> v� f'� L`I t 51YP-72 T �D N. R ��j(circleone <br /> U.Type of Building(check all that apply) Lot# <br /> 1�1 or 2 Family Dwelling-Number of Bedrooms (� Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> D'Tmvn of 04�-14A4 <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A' ❑New System 0 Replacement <br /> ep System Q Treatment/Holding Tank Replacement Only Q Other Modification to ExistingSystem(explain) <br /> B. ❑Permit Renewal Q Permit Revision ❑Chamge of Plumber Q Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner V I��"J <br /> IV, a of POWTS S stem/Com onent/Device: Check all that apply) <br /> 1 <br /> ❑Non-Pressurized lit-Ground ❑Pressurized Mround ❑At-Grade (Mound>_24 in,of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank Q Other Dispersal Component(explain) Q Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> �isv l o yW 1 1150 ��o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> GaIons Gallons Units E <br /> New Tanks <br /> Septic or Holding Tank <br /> DosinsCbamber bob <br /> ME Rea onsibW Statement-I,the understgaed,assume responslbiiity for instailatian of the POWTS shown on the attached plans. <br /> Plu 's N9&k <br /> (Print) Plumber's S' Mpftvm Number Bttmess Phone Number <br /> 0/9i I <br /> Plumber's Address(S 4City,State,Zip Code) <br /> VIlL County/Department Use Only <br /> Y1=A=-Anm15"- <br /> Approved ❑Disapproved Permit Fee - late lmued <br /> ❑Owner Given Reason far Denial <br /> IX.Conditions of ApprovalMeasons for Disapproval -�( - —--�(---�-/7 I� <br /> �t S be �om6' ►A Cep 'eG ( [E� E Q V t�E <br /> ��� � S-e,-Noc(c.�S Sw�� ✓n aP b� � Wi 6'cerise S�r� L <br /> FVl low a,U (C�-I.�-H-j 4�tc� S-EU-�f rPl�G>;i►^em.�1+5 <br /> UCT 0 3 2023 � <br /> Attach to complete plans for the system and submit to the County ants an pater rat teas than 9 to s 11 <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) <br /> (S y 25 Eck i 2to4 3 <br />