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County,Q <br /> { Safety and Buildings Division /'Ne7p-� <br /> p _ 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> § Madison,WI 53707-7162 , <br /> 1 <br /> Sanitary Permit Application State Transaction Number <br /> j 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 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 <br /> purposes in accordance with the Privacy Law,s. 15.04 I m,Stats. �,• / D,� ��/ <br /> 1. Application Information-Please Print All Information /1 n p� / <br /> Prope Owner's gName Parcel# p per? o2 39 510 <br /> PrCr)e iy Owner's Mailing Address Property Location �C <br /> —T-caX ID 3t,41�2�1 <br /> Govt.Lot <br /> �j,State Zip Code Phone Number /, Section <br /> circle one T N, R Eo W <br /> H.Type of Building(check all that apply) Lot# <br /> 3 <br /> ?or 2 ramify Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> L Public/Commercial-Describe Use ❑ City of �- <br /> Siate Owned-Describe Use <br /> �- CSM Number a g ❑ Village of <br /> dt <br /> ,, d /ate Rk'.own of N S <br /> Ili.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `lveyv System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> y � <br /> 3. ! u Permit Renewal i Permit Revision El of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> ❑ <br /> } Before Expiration Owner <br /> )7.Type of POWTS System/Component/Device: Check all that appi <br /> 77mon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> _ Molding Wank a Other Dispersal Component(explain) El Pretreatment Device(explain) <br /> 7.Dispersal/Treatment Area Information: <br /> Design.Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> i blY3 6 "� 3 <br /> T,Tank info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2 o `? <br /> New Tanks Existing Tanks o Y Q <br /> Septic or1106 r eJ e.5 L O <br /> Dosing Chamber <br /> V11.Responsibility Statement- I,the undersigned,assume responsibility for installation or the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> IYADE RUFSHOL\ 227691 ?IS-349 7286 <br /> ?;umber's Address(Street,City,State,Zip Code) <br /> PO BOX 514,SIREN,WI 54872 <br /> V111.County/Department Use Only <br /> i Permit Fee Dat Iss ed I WissuinAgent Signature <br /> ' Approved i ❑ Disapproved <br /> Owner Given Reason for Denial <br /> '_X.Conditions of Approval/Reasons for Disapproval D <br /> + GI,�I bars �e iV�/rie/1fs- 1J I� <br /> otlow au Lour `l -07) ` J U L U 8 2C24Uj <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 I <br /> inchei <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. i /Ii) wgZ5 ��'# 1(pg5 <br />