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`RIRr1/it Industry Services Division County . /_L <br /> ,y F _ 4822 Madison Yards Way f/14IfCT <br /> ' I $P Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> _ $ P.O.Box 7302 3'11V its —la <br /> li°��---.�'k Madison,WI 5302 .25 /�11- <br /> 'grs�ro,.t. X+o-7 lc* <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(jf different thanmailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary 34 0 g Cy',tol tl pr <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# <br /> ball t e I LtSD*- —1"-coc Lt goiec.o <br /> Property Owner's Mailing Address Property Location <br /> L/01 M.v(4616ny 111 Govt.Lot q <br /> City,State Zip Code Phone Number <br /> Rose/le IL (PO 172- '' '''A, Section 2-3— <br /> II.Type of Building(check all that apply) Lot# T 40 N R 0-- f�E or <br /> 1� Z 1 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> 0 State Owned—Describe Use CSM Number 0 Village of <br /> vFt P 130 krTown of"Sack$0 <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. ❑New SystemReplacementSystemExisting System(explain) (explain) <br /> ❑ Other Modification to ❑ Additional Pretreatment Unit <br /> TAtnk FA l l(Are <br /> B. ❑ Holding Tank ❑ In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> goo .1 q to q3z R3. 5 <br /> Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a o 'g o <br /> Tank InformationR <br /> New Tanks Existing Tanks 1 c p g <br /> 4 U iz. , rn ir. 3 5.. <br /> Septic or Holding Tank -7 7 1 co I w\2 S e r <br /> Dosing Chamber 7 <br /> V.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 MP/MPRS Number Business Phone Number <br /> iti <br /> Richard Hopkins > 225851 715-866-4157 <br /> • <br /> Plumber's Address(Street,City,State,Zip Code) t�,. <br /> 27760 Hwy 35 Webster WI 54893 <br /> VI.County/Department Use Only <br /> ZiApproved ❑Disapproved Permit Fee DateDate Issued Issuing Agent Signature <br /> 0 Owner Given Reason for Denial $ I`�� 5/22/2025 c i.kCp i'(/ti> <br /> Conditions of Approval/Reasons for Disapproval 4;7�// ' .5' <br /> �(.7 <br /> aA bGU,LS 57%i)4- <br /> RA LOI'' l Cadk-rt-(-7 0,0 S-tark re tu i/C AS Iy ( <br /> CCENAnLuJ <br /> vt ok (,t�-t-l/.i n -Tank loaw-f1 ��1° � MAY 2 2 2025 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 inches in sizeBurnett County <br /> Land Services Department <br /> SBD-6398(R.02/22) <br />