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Industry Services Division County <br /> ;�;, •;c, 1400 E Washington Ave <br /> a <br /> $p P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> $ ;fir Madison,WI53707 7162 <br /> $ /, - ✓ <br /> �-rwti.s..• _1 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383Z1(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> IS Rnt)tr[d`riot to nht�inino a--rum,tnwmw�N. A t'...,uft-,av°i°S for State owaWd Fu yr f0 ate tiUUMMd&V r DJCCL Address pf different than mailing address, <br /> .jJy.0 <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stars. gCot�G <br /> I. Application Information—Please Print All Information 7 <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location TCl X I 9 LP 3, <br /> � Z Govt.Lot 4 ko <br /> City,State Zip Code 1 Phone Number , %, Section <br /> t-j i 1, L Aj o(circle one <br /> II.Type of Building(check all that apply) � Lot# T N, R � E o&) <br /> IFI or 2 Family Dwelling—Number of Bedrooms Z Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number Q Village of / <br /> V'7 1"Z8' 5rTowm of <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑New System <br /> y �Replacement System ❑TreatmentJHolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit 1 1 Number and Date Issued <br /> Before Expiration Onn IN <br /> er <br /> IV.Type of POWTS S stem/Com onent/Device: (Check all that apply) <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.Dis ersal)Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation ZI <br /> -7 6` 65Z T . B B9y <br /> VI.Tank Info Capacity in Total of Manufacturer <br /> Gallons Gallons Units o E 8 <br /> New Tanks Existing Tanks <br /> u a a <br /> c`U in w t7 a <br /> Septic or Holding Tank 10k / 6 <br /> Dosing Chamber <br /> I _+_ <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Flu er's N (P <br /> rint) Plumber' ature MP/MPRS Ntunber Business Phone Number <br /> ��o �� <br /> Plumb-r s Address(Street,City,State,Zip Code) <br /> VIII.Coon /De artment Use Only <br /> Approved ❑Disapproved Permit Fee Ding Issued Issuing t Signatur <br /> 00 <br /> ❑Owner Given Reason for Denial S - <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> FAUA au coun+y atd Stu k r�fu re m��cfs �e a» <br /> m lit,,; viq lac.-for. S�$�cm t I! ?I . ,.._._,.._--._..T - <br /> rt•e's <br /> Attach to complete plans for the system and submit to the County only oa paper net less tban 8112 z 11 inches is sire �jF) <br /> 1.1 u <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br />