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! F�4 <br /> Industry Services Division ✓�^�A` <br /> I R1400 E Washington Ave t Number(to be tilled in by Co.) <br /> P.O. Box 7162 -a?�7 <br /> Madison, WI 53707-7162 r•. <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 govermnental 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 Servies. Personal information you provide may be used for secondary 9 DSy <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information `/46u, /21 vt✓ ��ol <br /> Property Owner's Name Parcel# <br /> ,", /�� O7-O�lD a-YO--/(.--D7-SAS-S8D <br /> ��av /vA h 0(1 s3 00 <br /> Property Owner's Mailing Address NOT. 11 Property Location <br /> Rd /3cx Govt.Lot <br /> City,State Zip Code Phone Number V4, Section 7 <br /> 4 d .� <br /> O �L,9/-5— (circle one) <br /> I1.Type of Building(check all that apply) Lot# T 'r/O N; R //� E or l� <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ElPublic/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 9Town of C e,le-1 A H <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 10 New System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other N[oditication to Existing System(explain) <br /> B. ❑ Permit Renewal El Permit Revision ❑Change of Plumber El Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of P. WTS,S stem/Com onent/Device: (Check all that apply) <br /> X_Non Pressurized In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.ofsuitable soil ❑ Mound<24 in.ofsuitable soil <br /> ❑ EfgldmaTarik ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VS's &/Treatment Area Information: <br /> Desigu'Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> qS0 1 . 7 4 q-? 41so 9,?. o <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> iVzw Tanks Existing Tanks o u a R <br /> a 5 in v w C7 a <br /> Septic or Holding Tank /Q d add O W/ <br /> Dosing Chamber- i <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 IvIP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VI I.County/'Department Use Only <br /> Approved ❑ Disapproved Pen-nit Fee O& Date Issued I uinQ Age Signature <br /> ❑ Owner Given Reason for Denial _• I� 1� ��� <br /> IX.Conditions of Me <br /> sons for Dissap'p_roval ,� - 2 <br /> e� oy SG�V�tG f SI urit/Wl l,s. <br /> %) <br /> Attach to complete plans for the system and submit to the County only on paper not less tha ti ins I inches in size 5;�)33 <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R0313) <br />