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A. County <br /> Industry Services Division eIn✓►�e` <br /> 1400 E Washington.Ave Sanitary Permit Number(to be tilled in.by Co.) <br /> It - P.O. Box 7162 — .2 79 <br /> ' 5 Madison, WI 53 70 7-71 62 <br /> '-i <br /> ._�Z�v <br /> foe T D <br /> 1'YjFY�,I I �' <br /> State TransactionNum Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,subudssion of this form to the appropriate governmental unit <br /> Ns- <br /> is,required prior to obtaining a sanitary permit. Note:Application forms for state-owned PO6(TS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary !7 / <br /> purposes m accordance with the Privacy Law,s.15.04(t)(m),Stats. <br /> h Application Information—Please Print A.11 Information <br /> Property Owner's Name Parcel# o <br /> Sctra..h Ko�-lCC _nvd — OlyoOo <br /> Property Owner's Mailing Address _ t, �1 Property Location <br /> 8� C {✓� 114 S / s C L` d" 7 G 9 Govt.Lot <br /> City,State 557t',.1 Zip Code Phone Number /, '/a, Section / 9 <br /> 5�i �!�w f' M/✓ (circle one) <br /> 11.Type of Building(check all that apply) Lot# T y � N; R /S�E or� <br /> 14 1 or2 Family Dwelling—Number of Bedrooms LI I Subdivision Name <br /> B lock# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number p Village of <br /> P23Q ® Townof swiss <br /> II1.Type of Permit: (Check only one box online A. Complete line B if applicable) <br /> A. ❑New System tq�/ <br /> Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of Plumber El Permit Transfer to New List Previous Permit Numberan Date Issued <br /> Hefbre Expiration Owner 1 57" <br /> IV..T"`e•of PON7S.S stem/Corn onent/Device: (Check all that appl ) <br /> No'n=1re razed in-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ,. $$ _ <br /> ❑Ko[atn`2 Tatik 11Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V4I3:s`ei dal/Treatment Area Information: <br /> F6�slow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 60o 7 �s7 �Go <br /> k Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a 43 a <br /> U � N <br /> New Tanks Existing Tanks o � <br /> C.U <br /> Septic or Holding Tank S 0 /.t 3!1 <br /> DosingCdamber- tl <br /> VII.Responsibility.Statement-I,the undersigned,assume responsibility for installation of the POtiVTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /��t,l`-✓� ��,,� � s&s-, 7i3-EGG � 411r'7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VH1.County/Depart ent Use Only <br /> Pen-nit Fee Dat Issued Issuing Agent Signs e _ <br /> Approved ❑Disapproved $q2 5e 'r 5 202� G! <br /> ❑Owner Given Reason for Denial �J <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ftf au s S D <br /> �Ow q,U aid S ✓�u�,•�rr�i��S NOV 04 2P" L <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 s 11 in hes in 51ZA--'�" <br /> Burnett County <br /> Land Services Department <br /> cRn-4zoQ /onlr17,5 <br />