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County <br /> _ f� '„_ • . Industry Services Division 13k✓►1C7� <br /> — rf` 1400 E Washington Ave <br /> t ) e r ir,7.10 9 Sanitary Permit Number(to be tilled in by Co.) <br /> 1 �i - P.O. Box 7162 <br /> ;f z <br /> g i r'�' Madison, WI 53707-7162 / <br /> 'F¢Ysi <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 /> the Department of Safety and Professional Servies. Personal information you provide maybe used for secondary y 7&Al <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. It-e' of 6 Rd <br /> I. Application Information—Please Print A-H Information <br /> Property Owner's Name Parcel# y I s—,�� <br /> Property Owner's Mailing Address Property Location <br /> Govt.G.ANa �1/A.. Tay- 1D 215 <br /> 35 <br /> 65-7 � RPX <br /> City,State Zip Code Phone Number y, y, Section <br /> L.Oki � GG, G/9 D (Cole one <br /> 1I.Type of Building(check all that apply) Lot# T L/ N; R 1.5 E o <br /> Xlor2 Family Dwelling-Number ofBedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ,❑ Village of <br /> V. 2 /►� dbtj ®Town of .Ttyll.S <br /> III.Type of Permit: (Check only one box on line 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 Transfer to New List Previous Permit Number ad Date Issued <br /> B. Permit Renewal ❑Permit Revision ❑Change of Plumber I�! <br /> Hefore Expiration Owner O I U <br /> IV..T-, e.of POWTS.S stem/Con onent/Device: (Check all that a I ) <br /> oa es;urized in-Ground ❑Pressurized[a-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> a - <br /> ❑>Ifolam�Tank ❑Other Dispersal Component(explain) ❑Pretreatment,Device(explain) <br /> VSD s"ersaI/Treatment Area Information: " t <br /> Design Fri w(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> Lf So . '7 3 Aso 9y.5, 93.5, W ) o <br /> VI.Tank Info Capacity in Total #of Manufacturer 2 <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks o <br /> a U m y cn w C7 a. <br /> Sep7Name <br /> k /OGd �OG4 <br /> DosO �D ) t 3i <br /> VIIty.Statement- I,the undersigned,assume responsibility for installation of the POtiVTS shown on the attached plans. <br /> Pluint) Plumber's Signature IvIP/NIPRS Number Business Phone Number <br /> Zleklo <br /> Plumber's Address(Street,City,State,Zip Code) i \ <br /> 7 3 <br /> Vill.Coun /De art ent Use Only <br /> Approved ❑ Disapproved Permit Fee Da a Issued �J Issuing Agent Signature _ <br /> ElOwner Given Reason for Denial /G�� Zo2 1 <br /> IX.Conditions of Approval/Reasons for Disapproval /j(� <br /> f'l�e+ aU Se.+WJS D �Vf �C, <br /> FOIIOw aLk (Dun+i irld S+C <br /> r �Md laic tleva-iais JUL 2 5 2024 <br /> Attach to complete p ans for the system and submit to the County only on paper not less than 8 112 s 11 inches n size <br /> Burnett County <br /> Land Services Department <br /> cRn_410efDr11isN 014-4-AV11<L lfq_ 4' I. <br />