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_ County <br /> -7 ,= `n� Industry Services Division �3t t ro r 7� <br /> zl See Re X isl� 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> -,, _ 36 <br /> _ P.O. Box 7162 ✓ `�� <br /> PAadison, N/I 53707-7162 <br /> State Transaction Number <br /> Sanitary Permit Application <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 Departtment of Safety and Professional Servies. Personal information you provide maybe used for secondary 59(4 O <br /> purposes in accordance with the Privacy Law,s.15.04(t)(m),Stats. <br /> I. Application lnformation-Please Print All Information }z <br /> Property Owner's Name Parcel# <br /> o1,i f/,e ✓'r oJY o00 <br /> Properrty Owner's Mailing Address Property Location Mak L p ; 2Z(P IS <br /> 41 9(e ( 13AI-t-I e7y_ 13 1 V I Govt.Lot <br /> City,State Zip Code Phone Number y, Y4, Section 9 <br /> Jm 0 K n Q ✓�A/ S-s-3 6 circle ones, <br /> 11.'Type of Building(check all that apply) Lot# T y/ N; R /� E or <br /> (1� l or Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial.-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number p Village of <br /> �J Towuof .5'WIJ.5 <br /> III.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. New System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. El Pemut Renewal ❑Permit Revision ❑Change of P�.-b:e,10 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> 1W-TYWe.of POVTS..S stem/Com onent/Device: (Check all that a I ) <br /> Non Pressurized fn-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑Flala n�Tarik ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> VSD:s"`eesaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil.Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> -3-0 . 7 G y3 RS ? 8 <br /> VI.'Tank Info Capacity in Total #of Manufacturer <br /> v <br /> Gallons Gallons Units n U <br /> New Tanks Existing Tanks o dl <br /> C.U m ti rn w U a <br /> Septic or Holding Tank O`0 p(� N f i 14 f0✓ X <br /> Dosing Chamber <br /> V11.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 IvIPMIPRS Number Business Phone Number <br /> /21 G K l�/ep lc i H 5 /(% `�� f� o��S�-S 1 7�-S= 1��� y45 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 776 D 1,V_2 Sy 8 93 <br /> VHL County/Depart int Use Only <br /> Approved F[Ibwisuapproved Peerrmit Fee Ell <br /> Issu (� Issuing gentSignatureer Given Reason for Denial + Z , <br /> IX Conditions of Approval/reasons for'Disapproval <br /> mkt+ W Se.* cks C C� 0�IC <br /> aid b44c re dui re ffU- s <br /> D <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1I inches! e <br /> Burnett County <br /> Land Services Department <br /> aRn_Fto.e tpn7t i z) <br />