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Industry Services Division County <br /> 1400 E Washington Ave UfN <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> it $ : , Madison,WI53707 7162 �'�}^( oZ 1'7 <br /> t. �_ ��` / 7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38311(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is renuirgd prior to obtaining a sari fry permit.Note:AyYli actor.forms jvr stalm—o uw Fv Yr 1 JiC a Stibumitted to Project Address of dlfIerent than mailing address) <br /> p'--' <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary o n purposes in accordance with the PrivacyLaw,s.15.04(1 m),Stars. Z86[ f�ft 1 /�5� <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> N6PJ 67-01,U-40-615-526'2ss Oi7at <br /> Property Owner's Mailing Ad Property Location — cL x <br /> 7D <br /> Govt.Lot <br /> City,State Zip Code Phone Number �'!., %, Secfloa <br /> 0 (circle on <br /> II.Type of Building(check all that apply) Lot it T N; R /,Z_E <br /> 1 or 2 Family Dwelling-Number of Bedrooms "I 3 Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> J9 To%%m of _T4C k�5O A_/ <br /> Ill.Type of Permit: (Check only one box on Gne A. Complete line B if spplicable) <br /> A* ❑New D <br /> System ( <br /> y t_q Replacemrnt System ❑TreatmenUHolding 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 Expitation Owner �'r1 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ( Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.ofsuitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Deti7ce(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) DispersalArw Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 992 gl S <br /> VI.Tank Info Capacity in Total <of Manufacturer <br /> V <br /> Gallons Gallons Units U T g <br /> New Tanks Existing Tanks <br /> c`,U in w y is t7 a. <br /> Septic or Holding TmA <br /> Dosing Chamber ✓� 1- <br /> VII.Responsibility Statement-L the undersigaed,assume responsibility for Installation of the POWTS shown on the attached plans <br /> Plun cr's Name(Print) Plumber's talc MP/MPRS Ntu7rber Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code)Wel <br /> t <br /> VIII.Coun /De artment Use Only <br /> Approved ❑Disapproved Permit Fee CC I <br /> GD�ate Issued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial S �� ` 131Z aZ N <br /> IN.Conditions of Approval/Reasons for Disapproval <br /> -Ec( i� S Fn1 � <br /> I w aV caA a� s 4 WU tkYLU1+ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 lax 11 tube's to sine�n �S o 2o2 LU) <br /> t7 L — <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br />