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Industry Services Division County LA(O e f <br /> r 9 itary Permit Number(to_be tjlled in_by-Co} <br /> ,5F 1400 E Washington Ave San <br /> , <br /> P.O. Box71f2 <br /> Madison, WI 53 70 7-71 62 <br /> ti y•.� <br /> Sanitary Permit Application <br /> State Transaction Number <br /> [n 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 !L'� 9 Thumpso i <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. /' <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Property Owner's Mailing Address Property Location <br /> �L4 5 g --V7 G <br /> z �n i uX [[I) st��3 <br /> ovt.Lot = <br /> City,State //�� 11 - y�7W ,7S <br /> ip Code Phone Number /, %, Section ZS <br /> Z,ANft'r gIrvVG 1 ct e�AAs 1-o0-7-7 Ift. D_'L qS `,�, cucleone <br /> H.Type of Building(check all that apply) Lot# 4, T�N; R E or <br /> X'I or2 Family Dwelling-Number of Bedrooms 3 u7-0)Z--Z-W-/S-zS-s Subdivision Name <br /> o -na -G 2t700 <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> of- <br /> El City <br /> ❑State Owned-Describe Use C`S'I-vl7Number p Village of _ <br /> Y 1 p Town of [X( ��( <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> El❑New System XReptacement System Treatment(Holding Tank Replacement Only ElOther Moditication to Existing System(explain) <br /> B• 0 Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Hefbre Expiration Owner 412020 L9 120 Iq 85. <br /> IV..i '`e•of POVFV S,S ste'm(Com onent/Device: (Check all that apply) <br /> om P essunzed in-Ground ❑Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.ofsuitable soil ❑ Mound<24 in.ofsuitable soil <br /> ❑>ELalainyTaiik ❑Other Dispersal Component(explain) ❑Pretreatment,Device(explain) <br /> V: I/Treatment Area Information: <br /> Desgn Ptow(gpd) Design Soil.Application Rate(gpd4. Dispersal Area Required(s� Dispersal Area Proposed(st) System Elevation <br /> ysa • � -7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units n o <br /> New Tanks Existing Tanks U N <br /> o °= 2 <br /> c`U In Yn cn w C7 ci <br /> ' z <br /> Septic or Holding Tank n�O 2s� 1 e s <br /> Dosing Chamber- <br /> VII.Responsibility.Statement- I,the undersigned,assume responsibility for installation of the PO�WS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature IVIP/MPRS Number Business one Number <br /> t 4,0 k�N ZZ 585 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 2���o w b - e-C' w� S�/ CAI <br /> Vial.Coun /De artment Use Onl <br /> LApproved ❑Disapproved Permit Fee Data Issued Issuing Agent Signature _ <br /> ❑Owner Given Reason for Denial <br /> y25 Sl 12C)ZS <br /> I .Conditions of Approval/Reasons for I)isagprovaI D <br /> NI.Q.A.-�- <br /> Lew ct,U Cw,147 Old S-la 4 r�u�re�S FAP 2�2F) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to s1l incl as in si Burnett County <br /> Land Services Department <br /> #A5u:,o! <br /> S B D-6398 1R03 131 ' <br />