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County <br /> rr�rk N-,a, Industry Services Division �b6o.6 <br /> r` ' _ 1400E Washin ton Ave 9 Sanitary Permit Number(to be tilled in- <br /> PO. Box7162 �an PAadison, WI 53707-7162 `am �"��� lp � <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 POb(TS 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 3 /Y <br /> purposes in accordance with the Privacy Law,s.15.04(i)(m),S tats. / <br /> I. Application Information—Please Print A-H Information R,G( <br /> Property Owner's Name Parcel# <br /> Cher•-,� � s G1-a il:t'`re tS-Qr-s�S= 3/3 Sao <br /> Property Owner's NIa ing Address Property Location <br /> 69700 50 h C s c./C- T✓ Govt.Lot _ 9 <br /> City,State Zip Code Phone Number %, y,, Section / <br /> �/ t1 �� �s-07 (circle one) <br /> nvt.✓ ,p T yU N; R/,LEor� <br /> 1I.Type of Building(check all that apply) Lot# <br /> I or2 Family Dwelling-Number cf Bedrooms Subdivision Name QQJ <br /> Block# Wl,all,'4 /lUO4v►4/,S <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of ` <br /> El Owned-Describe Use CSN[Number ❑ Village of <br /> Town of Joke, 3 0In <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System <br /> y El Replacement 5ystern ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Aha._�.11?lumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> of P0WTS.S stem/Com onent/Device: (Check all that a 1 l'retsuri ) <br /> - zed in-Ground ❑Pressurized[n-Ground ❑ At-Grade El Mound 24 in.of suitable soil El Mound<24 in.of suitable soil <br /> `Non- <br /> ET,NiamTT'a ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VSD s"er aI/Treatment Area Information: t <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(s f) Dispersal Area Proposed(st) System Elevation <br /> 7 <br /> VI.Wank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units n ? B o <br /> U � <br /> New Tanks Existing Tanks o 2 a <br /> c`.0 cn ti m wC7 a <br /> f <br /> Septic or Holding Tank a, aG <br /> xog <br /> Dosing Chamber_ t 3t <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Str6fet,City,State,Zip Code) <br /> /,I-� ��53 <br /> V111.Couny/Departmenf Use Only <br /> Approved ❑Disapproved Permit Fee O Date Issued Issu' o ent Sign <br /> El Owner Given Reason for Denial $ �/./r <br /> IX.Conditions of ApprovalfReasons for Disapproval D <br /> meek att S�-l-ba�,l�S re �em�•�fs <br /> da-k C0WW&WV1r MAnuojs -o V es►oo Z. 4l & bar Scut_ Dn ID+J <br /> OCT 2 6 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t_x V in hes in Burnett County <br /> Land Services Department <br />