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y, =S.ita <br /> .a-•J�-�'i. .. <br /> In <br /> Services Division e <br /> 1400 E Washington Ave ry Permit Number(to be-filled in by Co.) <br /> P.O. Box 7162 SAM V In-7 <br /> Madison, WI 53707—71 62 <br /> � �-s -7 ✓ <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this Form to the appropriate govermnental unit <br /> is,required prior to obtaining a sanitary permit, Note:Applicatioa forms for state-owned POGVCS 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 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. A lication Information-Please Print All Information <br /> Property Owner's Name Parcel# SOS ba,! <br /> Property Owner's Mailing Address ,l Property Location e j 1? (z W <br /> -7 P3-- IV ��t (r1cvt L�� Ur Govt.Lot <br /> City,State Zip Code Phone Number / %, Section 3�/ <br /> L/ {,v� f 153 (circle one <br /> dlh b a`� T y N; R 4E o <br /> 11.Type of Building(check all that apply) Lot# <br /> �l or Family Dwelling-Number of Bedrooms 2- Subdivision Name <br /> Block# <br /> ❑ m Public/Comercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSb[Number p Village of <br /> V,� f �6b 5rTownof 5 w15 3 <br /> IIi.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber FEI Permit Transfer to New List Previo,1q permit Number and Date Issued <br /> Before Expiration I ner <br /> ------------- <br /> 1V..f" e,of Pf3WTS..S stem/Com onent/Device: (Check all that apply) <br /> ',9-N-q I'e razed rn-Ground ❑Pressurized In-Ground El At-GradeEl Mound>24 in.ofsuitable soil El Mound<24 in.of suitable soil <br /> - <br /> ❑Ii3(atnyTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> etsaI/Treatment Area Information: <br /> Dei i.ThTr(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area 4(st) m Elevation <br /> lso '7 is' ��0 � <br /> 6Do,ing <br /> nk Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks v w <br /> m y vs wU a <br /> Holding Tank s�f7 O / �/ �yY A�O <br /> hambzr_ 31 <br /> V11.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the PObWS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> �77(0 /4/--, 3S GV.BL31r W.- S YSs3 <br /> V1II.COUn /Pe artment Use Only <br /> Approved El Disapproved Permit Fee D� Date IssuedI u' g gent lure _ <br /> El Owner Given Reason for Denial � ` ply <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> rnte.-� <br /> �sw cou.ir�,-t� au9 S-Iu-L-e Ye�c,�;t rt.Yu.Q.n,+S <br /> a66 bal' Scale an Lo+ SEP 21 2023 <br /> ttacb tp complete pla £or t e system and sirbm't to th'County oniy on paper not less than 8 uz x i l inche s1 <br /> d <br /> ' <br /> � 'sc�ose�`� -1� JA 5 f tE-h_c)/7 Burnett County <br /> Land Services Department <br /> SBD-6398(R0111) <br />