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Y T t1 <br /> Industry Services Division County <br /> 1400 E Washington Ave ` el <br /> P.O.Box 714G2 Sari tazy Pennit Number(to be Sled in by Co.) <br /> r1 Madison,WI53707-7162 AN p-3— L52 G5L(937 <br /> Sanitary Permit ApplicationT "°�''' ' <br /> In accordance with SPS 383.21(2) Wis.Aden.Code,submission of this forrn to the appropriate goveramental unit <br /> is required prior to obtaining a sanitary permit Note Application fomts for stateowacd POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal htf oration you provide maybe used for secondary <br /> oses in accordance with the Privacy Law s.15.04(1)(m Stats. ' <br /> I, Application Information—Pleop Print All Information <br /> Property Owner's Name -r Parcel# <br /> v6ki a -W Z- 04-15- -o r0eo <br /> Property Owner's Mailing Address propay?ocation <br /> 44 /3310 <br /> 219707 Govt Lot <br /> City,State f ' Zip Code Phone Number �IF V,�Y., Section <br /> dq,u J( oa <br /> T JiD N; R Eor� <br /> H.Type of Building(check aA that apply) Lot# <br /> 91 or 2 Family Dwelling—Number of Bedrooms � Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Numbs ❑Vrliap of <br /> 3 Town of OA Ir-[</i►+ <br /> I11.Type of Permit; (Check only one box on line A. Complete tine B If applicable) <br /> A' ❑New System <br /> ys Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to ExistirtgSystem(explain) <br /> $. ❑Permit Renewal ❑Permit Revision ❑Ct>mp of Plumber D Permit Tnmfer to New List Previous Pa mit Number and Date issued <br /> Before Expiration Owner � �V <br /> IV. a of POWTS S statn/Com onent/Device: Check all that apply) <br /> allon-Pressurized in-Ground ❑Pressurized In-Grotmd D At-Grade ❑Mound!24 in.ofmitabie soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ©Pretreatment Device(expinin) <br /> V.Dis ersaWrestment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3O5 1 ' S 1 600 660 17Z.6 <br /> VI.Tank Info Capaaty in Total €of 141amrfacturer <br /> (3911= Gallons Units <br /> New Tanks Edging Tanks <br /> V t'd m 1sf3 0. <br /> Septic or Holding Taal p p D� f T Ri <br /> ooategchamber <br /> VII.R onsibility Statement-L the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> P u 's Name(Punt) Piumbce S MP/MPRS Number Business Phi Number <br /> 0.51 <br /> Piumb'r's (Street,City,State,Zip Code) <br /> r Amyl� 1k 4 w ol-&- vl- 5�fbg <br /> VIIL gaptylDepartment Use Only <br /> Approved Disapproved $��500 8//7Z- 7 � <br /> D Owner Given Reason for Dental <br /> M �- all &- D) IE C E-", �V E� <br /> �T,V5 �I-e 5:zAf,-q .5 <br /> 4P� - oe`i ni <br /> AUG 0 8 2023 <br /> Attach to cemplale pleas for the s}stcm and sabmlt to the Quaq aaq an paper ast less than g ill z 11' 1s <br /> Burnett County <br /> Land Services Department <br /> sy25"" . <br /> SBD-6398(R 08/14) r)Aj-,c� *( i-V <br />