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Industry Services Division County <br /> 1400 E Washington Ave <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162.t,� L tOJO b <br /> Sanitary Permit Application State Transaction Number <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 POWTS are submitted to Project Address(if different than mailing address) <br /> ru... ... : . �..u:..ats. uu�.,�.r.�..�...u, u� �:�. _ .. W, 3�iec carlow <br /> purposes in accordance with the PrivacyLaw,s.15.04(l)(m),Stars. <br /> I. Application Information-Please Print All Information 'J <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location "'ram VD Z2-7 S3 <br /> gall v/ f I ! Y `' Govt.Lot l" r <br /> City.State Zip Code Phone Number y4, V4, Section <br /> A e` /n N �s /7 !1 I n pie vuc <br /> C' `r'�' r�✓ '• T N; R E or <br /> II.Type of Building(check all that apply) ^ Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms p( Subdivision Name Q <br /> Block# 16 M{N'J4 f„/QA/(t9/J <br /> ❑Public/Commercial-Describe Use ❑City of- <br /> CSM Number ❑Village of <br /> ❑State Owned-Describe Use <br /> (;-Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. Change of Plumber List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑ Permit Revision ❑Pettnit Transfer to New <br /> Before Expiration Owner <br /> IV.Type_ / <br /> o-fPO`WTS System/Component/Device: Check all that apply) <br /> x#4M-, / - T)__,.....-)__J T� !`_�...., M I.(-,,,1_ n 1I....-1. •I.- _r....I...LI,._...1 1 1 L .�I l- _r...1.,. _.....1 <br /> W6001* <br /> ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow b (gpd) Design Soil Application Rate(gpdsfl Dispersal;rea Required(sfJ Dispersal Area Proposed(sfl System Elevation <br /> 33ka 8 6 1l 1 2 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a ; U _ H <br /> New Tanks Existing Tanks d p 2 <br /> aU in 05 wc9 a <br /> Septic or)iolding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name nnt) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> l "7 /l k 70 7%40 <br /> VIII.Coun /De rtment Use Only <br /> Permit Fee Date issued Issum Agent Signature <br /> Approved ❑ Disapproved $ n ZCZ <br /> ❑ Owner Given Reason for Denial G <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 3-29 7 5 <br /> and S4v:-k rP J u 6 fe-MLA-f S D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x i in size ^ <br /> JUN GO 4 20 U <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br />