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J �,�•t Industry Services Division County <br /> 1400 E Washington Ave _ <br /> p v <br /> p P.O.Box 71.62 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 �J-24_ou I <br /> 4 - 2`, <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 repuirerl�riM to nhr�inin�o n S��iMry 1^,errliL 1`10te.nY�ii.lino/:lvi/u lvr Siaic-vwuui 1�vW T o df 5uburit(id to "rro}eet Address of dil erent than mailing aridness) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary —Fa x 1 CJO 3 <br /> u oses in accordance with the Privac Law,s.15.44(1)(m),Stars. ' <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel <br /> // # <br /> `6& <br /> Property Owner's Mailing Addr(esss, Property Location <br /> Z / /rot^ v L Govt.Lot <br /> City,State Zip Code Phone Number t %; Section LS <br /> (i Q A/ 55Z7g S ^b rote one <br /> II.Type f Building(check all that apply) Lot tr <br /> T qD N, R E o <br /> [Al or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block R <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> r itf �9 a Toun of VF'tb� <br /> J <br /> 111.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 /> B• ❑Permit Renewal ❑Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑Permit Transfer to New <br /> Before Expiration Owner <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,of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Trestment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 1 1 yZa! I �952- 1 i 91/Z /j925r <br /> VI.Tank Info Capacity in Total it of Nlanufacwrer <br /> Gallons Gallons Units ' o <br /> New Tanks Existing Tanks <br /> It U in y rn i•t7 ii <br /> Septic or Holding Tank a0 QO0 <br /> Dosing Chamber <br /> V11.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plun er's Name(Print) Plumber's ' tare MP/MPRS Ntupber Business Phone Number <br /> Plumhpr's Address(Street,City,State,Zip Code) <br /> �6,5`I AoAw I/-- 4/_ i5lvbq:� <br /> VIII.Colin !De artment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issu / issuing Agent Simmium <br /> ❑Owner Given Reason for Denial S���v0 101221��-/ <br /> iX.Conditions of Approval/Reasons for Disapproval c , <br /> Nam- <br /> [o IE <br /> w ,� CCU CC.[1 !1 <br /> Attach to complete plans for the system and submit to the County only on paper not less t n S t2 z t t inches instec <br /> l; Li <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R 08114) <br />