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' County <br /> „_ Industry Services Division <br /> 1400 E Washington Ave Sam Permit Number(to be filled in by Co.) <br /> �' <br /> �. 'i. P.O.Box 7162 �N..� / 3 <br /> ' Madison, Oil 53707-7162 <br /> 14< <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 governmental unit <br /> is,required prior to obtaining a sanitary permit. Note:Application forms For state-owned POGVFS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 29 Ml Il ervo C t <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel Ll 1-/16-36-3- O �- --0 a 0 <br /> J0�00- 6 19 606 <br /> Property Owner's Mailing Address Property Location <br /> 11-7(,S_ Vt Gta✓' Poi+�` 9Govt.Lot -Y <br /> City,State Zip Code Phone Number /, V4, Section 36 <br /> Aii p A?Al 5.r0 3 (circle one <br /> Il.Type of Building(check all that apply) Lot# T Y 1 N; R /6 E or(�J <br /> l or Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number p Village of <br /> 9 Town of SW/J1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Replacement Systern ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑LChanga��of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner ` N V <br /> IV.. '`e,of POWTS.S stem/Com onent/Device: (Check all that apply) <br /> on-Vr s�zed Ea-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑€iglgtnTarik ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VtD:sMI/Treatment Area Information: �. <br /> Design Ftow(gpd) Design Soil Application Rate(gpdsfl Dispersal Area Required(sfl Dispersal Area Proposed(st) System Elevation <br /> 30� � yj tis`v 9ti. 3 � 9� <br /> VI.Tank Info Capacity in Total #of Manufacturer c' <br /> Gallons Gallons Units U a� <br /> New Tanks ExisdngTanks <br /> a.U cn y cn w C7 P. <br /> Septic or Holding Tank <br /> Dosing Chamber S OrJ �'�� <br /> V1I.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the PO1VTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature IVIP/MPRS Number Business Phone Number <br /> Jal <br /> Plumber's Address( treet,City,State,Zip Code) <br /> a�7'74o f/w 3S tv-eSS-le- � �tf6% <br /> VIII.County/Department Use Only <br /> Permit Fee Date[ssued issuing Agent Signature <br /> Approved ❑Disapproved ;9 I,, <br /> El owner Given Reason for Denial q26 l� 2- 4 2� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Aai S rJ "2024 <br /> �OI�Ow at l CDqAl s <br /> Burnett Count <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/1 x 11 in es in An erVIC@S Department <br /> Con <br />