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County <br /> Industry Services Division :3urn e0 <br /> �_ _ 1400 E Washington Ave Sanitary Permit Number(to be fit in..by Co.) <br /> �+ <br /> - P.O. Box7162 SIN 2�-D� <br /> PAadison,WI 53707-7162 <br /> -24-055 (1054$ <br /> Sanitary Permit Application State Transaction Number <br /> (n 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 PO4VTS 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 27 02- <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. W• Con n'wi L(G j70r <br /> I. Application Information—Pleise Print All Information <br /> Property Owner's Name Parcel# <br /> l c ti etc S G�1 a✓� Ic 07,as v-� -w-16 3-�=S as-a�`l <br /> -, Ca 16 b ao <br /> Property Owner's Mailing Address Property Location <br /> /�0'1 / e,t+ I/VA.y Govt.Lot q <br /> City,State Zip Code Phone Number /, '/<, Section 13- <br /> Al-e-e h e. 9J-6 (circle one) <br /> II.'Type of Building(check all that apply) Lot# T �/� N; R �` E orN <br /> Nf I or2 Family Dwelling-Number of Bedrooms 9 Subdivision Name <br /> Block# <br /> ❑Public/Commercial.-Describe Use <br /> ❑ City of . <br /> ❑State Owned-Describe Use CSNI Number p Village of_ <br /> Town of 140et, <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System p y❑Replacement S stein ❑Treatment/Holding Tank Replacement Only ❑Other Iv[oditication to Existing System(exp lain <br /> ) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV..C: i of POWTS.S stem/Com onent/DeAce: (Check all that app ly i <br /> ❑_K a I',essurized In-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> ❑K [am=Tank ❑Other Dispersal Component(explain) ❑Pretreatment,Device(explain) <br /> VSDs ensal/Treatment Area Information: a <br /> DesrrFlow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks ExisdngTanks o a m <br /> a,U cn ti n w C7 a <br /> Septic or Holding Tank �db a /l5G0 <br /> DesingChamber- GCO (p(/dVVr 31 <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 MP/MPRS Number Business Phone Number <br /> 01 <br /> Plumber's Addresss(Street,City,State,Zip Code) <br /> 7_760 /�'/w y 315-- w A'c r <br /> VIII.Coun /De artment Use Only <br /> Approved El Disapproved Permit Fee Date Issu7;20zq.1 <br /> Issuing Agent Signatt- <br /> -4 <br /> ❑Owner Given Reason for Denial YG v S ( (,1(� <br /> I .Conditions of Approva]/12easons for Disapproval <br /> Meek k4w� LE ��I Cs <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inclinnik <br /> Burnett County <br /> Land Services Department <br /> CRrI_�ZO4 ions i�� <br />