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,✓,i;::za'a=;::, Fun <br /> Indust Services Division1400 E Washington Ave t Number(to be tilled in by Co.) <br /> P.O. Box 7162Madison, WI 53707-7162 �� 3 <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 govetmmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO�VTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal infon-nation you provide may be used for secondary d 8 g c{ <br /> purposes m accordance with the Privacy Law,s.15.04(I)(m),Slats. J <br /> I. Application Information—Please Print All Information Lon �/�- /2v( <br /> Property Owner's Name ry�y� oPar el 1"Yd,l e�. )7—SOS- t70 a <br /> %KEG /i7,- � e7/ Oda <br /> Property Owner's Mailing Address Property Location --� �D 3(9qZZ <br /> Y3 Folly /ytd �d 4 P T 36 Govt. d <br /> City,State JZip Code Phone Number , <br /> /<, Section 1 <br /> 11;1'tb y to/ r j�, C���fj circle one) <br /> 11.Type of Building(check all that apply) q Lot# T �D N; R E or� <br /> 01 or 2 Family Dwelling—Number of Bedrooms �` 3 Subdivision Name <br /> Block# <br /> ❑Public/Cotrunercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSNI Number Village of <br /> V2q 1 3`�J Toavnof <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) [• <br /> A. <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other N[oditication to Existing System(explain) <br /> B• El. Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T e.of POW'T'S,S stem/Com onent/Device: (Check all that apply) <br /> Non Press nzed In-Ground ❑ ressur In-Ground ❑ N[ound ❑Pressurized In-Gd ❑ At-Grade _roun >24 in.of suitable soil Mound<24 in.of suitable soil <br /> ❑ 561dmg Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> wDsensal/Treatment Area Information: <br /> DesfgsFlow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 30a , 5- to o 0 oa 93. ! � C73. 6 . <br /> VI.'Tank Info Capacity in Total #of Manufacturer <br /> 1) <br /> Gallons Gallons Units o B <br /> New Tanks Existing Tarries o u m Vd <br /> a 0 m y v, wC7 a <br /> Septic or Hold ng rank 0 (r/D �ij0 <br /> Dosing Chamber_ �i7 O J�O(� 1 <br /> VII.Responsibility.Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatur MP/MPRS Number Business Phone Number <br /> �ic��. f/o l�►Hs JL�J� ��,T�s`i 7/S- �Y �/�S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> l <br /> )'776o h/w• 3S W-e4rly-, w1 S�89 <br /> VIII.Coun /De artment Use Only <br /> Approved El Disapproved Permit Fee Dat [s eed (� Issuing Agent Signature _ <br /> ❑ Owner Given Reason for Denial $ " �`5~ 7 GOZ <br /> IX.Conditions of ApprovalfReasons for Disapproval <br /> au S D �C� � �M fr <br /> allow G c a,�cQ s-I e r�uirern�n fi F; ..V <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 s t l inch in <br /> Burnett County <br /> SBD-6393 (R0313) <br /> Land Services Department <br />