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Industry Senices Division County L <br /> 1400 E Washington Ave V,,,vel! <br /> �-1 S -' P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> PS Not Instal' Madison,WI53707-7162 �,'� -��/ ���$7 <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. � <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# w <br /> le414� x1ler Aff n <br /> Property Owner's Mailing Address Property Location <br /> C100 T-I &v f/ Govt.Lot <br /> City,State Jam( Z`ip Code Phone Number y, �/,, Section _7 <br /> /i e. bro V e ✓�O�b T �� N; R l irclE o W <br /> II.Type of B ding(check all that apply) Lot Y <br /> I or 2 Family Dwelling-Number of Bedrooms 7 Subdivision Name <br /> Block R <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 06 V Z nz/ 0 Town of 5 LV �! <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable)f b <br /> A' a New System Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> TNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Ivlound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersallTreatment Area Information: <br /> Design Flow(npd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3da . '7 7,v l y32 C12 5- <br /> VI.Tank Info Capacity in Total of Manufacturer <br /> Gallons Gallons Units o <br /> G <br /> N <br /> New Tanks Existin__Tanks a = 2 <br /> U in ; <br /> scptic or Holding Tank 75- 76-0 W e5 er <br /> Dosing Chamber <br /> V1I.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu ber's Name(Print) Plumber's Si MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> � t l,, t / b <br /> VIII.County/ e artment Use Only <br /> El <br /> Approved ❑ Disapproved Permit Fee Date <br /> Issued <br /> sui g ent e <br /> ❑Owner Given Reason For Denial S l��/ 711//v <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> n DIF' F- <br /> Attach to complete plans for the system and submit to the County only on paper not less than S tt2 s 11 Inches i <br /> .i J L - 6 2022 <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br />