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Industry Services Division County <br /> %� "•._ 1400 E Washington Ave <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 23 <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 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 `2/&e) 3 -yak klj.134 7,3 <br /> purposes in accordance with the Privacy Law,s. 15. 1 m,Stars. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name - <br /> Crt'c� <br /> Property Owner's Mailing Address Property Location <br /> yi Z C r--k i,ACJ C,3 L IL Govt.Lot 4 <br /> City,State Zip Code Phone Number /,, /4, Section <br /> 1 S at-dt I hJ 5Sb Vb / -1l ,3— z 2�'-2 yfi circle one <br /> # T 32 N, REo.. <br /> H.Type of Building(check all that apply) Lot <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 ❑ Village of <br /> --� L <br /> V 7 PG� 07 ❑Town of 'L- <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A- New System ❑Replacement System ❑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 Owner <br /> IV.Type of POWTS S stem/Com nent/Device: Check all that <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 ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> _ „y <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks o <br /> a U in ;, rn is C7 a <br /> Septic Hokhag Tank <br /> Dosing Chamber `r <br /> VII.Responsibility Statement- t,the undersigned,assume responsibility for installation of the POWTS skews on the attached plans <br /> Plumber's Name(Print) Plum MP/MPRS Number Business Phone Number <br /> �150,�► l �.f�SS 1'ZfS`C�S3-2 Boa <br /> Plumber's Address(Street,City,State,Zip Code) _ <br /> V1I1.County/De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial S 7 I I 117 2�2 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Q at I �t+Io-U,4-S C <br /> n aid s-fa- re <br /> Follow a Cot L � <br /> Ic..n�- -b 4,4 be- a rVi Ceti a n1 u <br /> � aO In 1 0 Ir E 2 <br /> Ameh go c&mNeae Naas for ere sy"m and saitait to the County*sly on paper arc Jen thsa iocbm in sir <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R 08/14) ,�O_ r I N l q <br />