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Industry Services Division County <br /> 9 �s 1400 E Washington Ave U ftvdl- <br /> (sl S P.O.Box 7I62 <br /> Madison,WI 53707 7162 <br /> Sanitary Permit Number(to be fined in by Co.) <br /> l&'s <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.2I(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> IG ICCltliiMt nri ��M flr to ninmbo itMCM111tm�ry p�,t N�iv Application 1V1llij for state-o-wacd aPF^iW T S are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> u oses in accordance with the Privacy Law,s.15.04(1)(m),Stars.I. A ��� <br /> Application Information-Please Print All Information n e <br /> Property Owner's Name Parcel# <br /> CND !10✓ 0 �- -oo!v)2ab <br /> Property Owner's Mailing Address Property Location -1-0.1L 1l� G2 q I <br /> Govt.Lot <br /> :�— <br /> Clt)�f rote Zip Code Phone Number Y4 %, Section t 3 <br /> blwuL( �f,• circle on <br /> II.Type of Bu ding(check all that apply) Lot# <br /> TN; REo <br /> �1 or 2 Family Dwelling �-Number of Bedrooms Subdivision Name <br /> Black# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Z F qz- ®TO,,,of_ TA6 r'l <br /> Ill.Type of Permit: (Check only one box on tine A. Complete line B If applicable) <br /> A. <br /> ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> $ ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration owner I NV <br /> IV.Type of POWTS System/Component/Device: Check all that a 1 <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3010 . 5 1 612�- 1 91.G `1Zo <br /> VI-Tank Info Capacity in Total r of Manufacturer <br /> Gallons Gallons Units u <br /> New Tanks Existing Tanks ,s u U u <br /> Septic or Holding Tank- <br /> Dosing Chamber Jam() <br /> VIi.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POW'rS shown on the attached plans. <br /> Plun or Name(Print) Pittmber's MP/MPRS Number Business Phone Number <br /> �4/ P'61 9 A—�L] <br /> Plumb-r s Address(Street,City,State,Zip Coda)` <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Isssued / Issuing Agent Sigaature / <br /> ❑Owner Given Reason for Denial $qG`� v 2a 2�Z / W —J I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> y � nD POM�y f <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to z 11 inches in �UG 2 Q 2024 <br /> �i <br /> U <br /> Burnett County <br /> SBD-6398(R 08114) Land Services Department <br />