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WAR! for <br />r f*. <br />Industry Services Division <br />1400 E Washington Ave <br />County 7 AjeT^r �;Jx0 <br />1✓�� 7334 <br />1 f i= �� <br />P.O. Box 7162 <br />Mattison, WI 53707-7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />r j <br />, r l9 —to 3 <br />t+- U , <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis, Adm. Code, submission of this form to the appropriate governmental unit <br />�,' A <br />Project Address (ifdillerent than mailing address) <br />is required prior to obtaining a sanitary permit Note: Application forms for state-oaered POWTS aro submitted to <br />the Department of Safety and Professional Servi= Personal information you provide may be used for secondary <br />in accordance with the Privacy Law s. 15-04(l XrnStats. <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />KIC} IOQ)M�_ CERALbVVE L' , P6A1JLA1K-&t)A[ 19,L(sT <br />Parcel # <br />o7-O�z-y-40f� 135 i5=zs =o/� <br />Property Owner's Mailing Address <br />Property Location r <br />53 £fes ST <br />,NWI .— <br />Goer. La - <br />._ y4, _ y Section <br />City, State <br />Zip Code <br />Phone Number <br />IVIEWAACAJIE,LAJI <br />:5117-5I <br />circleone -� <br />T �Ga N, R �-� E _`°� <br />H. Type of Building (check all that apply) <br />Lot # <br />I or 2 Family Dwelling - Number of Bedrooms Z <br />( <br />SubiiTMdonName G;. i%z E T 6EAiR, <br />413M. /O lVyAC_&< V144A1-- <br />Block# <br />❑ PubliclComme tial - Describe Use <br />❑ City of <br />❑ State Owned - Describe Use <br />❑ Village of <br />CSM Number <br />✓ <br />Town of _ACKC 0 <br />III. Type <br />of Pamir (Check only one box on line A. Complete line B if applicable) <br />A. <br />New System <br />❑ Replacement System <br />❑ TreatmartJHoldin Tank <br />g Repbxxmemt Only <br />❑ Other Modification to Existing System (explain) <br />B• <br />❑ Permit Renewal <br />❑Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type <br />of POWTS S NDevice: Check all that <br />IgNon-Pressurized In -Ground ❑ Presstaiaed In Groud ❑ At -Grade ❑ Mound 2:24 m. of suitabk soil ❑ Maud <24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (vgAam) ❑ Present Device (explain) <br />V. Dispernsalfrnematmeut Area Information: <br />Design Flow ($pol) <br />Design Sal Application�(tsfl <br />D At- Required (sf) <br />Dispersal Area Proposed (so <br />System Elevation <br />3 <br />0.11 <br />L129, 67 <br />s(� <br />J&. _50 I <br />VL Task Info <br />Capacity in Total # of Manufacturer <br />Gallas Gallon Units <br />New Talcs Existing Taks <br />u p sU' epi <br />m <br />/O6 0 <br />on <br />septic ee"W&0rTW& <br />VQ. Ra Statement- the ^' r iraaihOor of the POWTS shover or the stYuied pians. <br />poasibitity 1, rsigaed,r-SS7_&_RJ <br />Plumber's Name (Print) J� <br />cL� y �� N �a� <br />PI Si <br />i`. <br />MPQtRM Number <br />'T <br />Business Phone Number <br />Plumber's Address (Street, City, State, Zip Code) <br />�,�U 13LA ' .<C0k Kl). i t;t tt _ Wsc <br />VIB. Couu rtmeat Use Only A <br />Approved <br />❑ Disapproved <br />Permit Fee 6 <br />O <br />Date Issued <br />L4suirrg Agee Si <br />❑ Owner Given Reason for Denials <br />376. <br />7 -fa -/F1 <br />IX. Conditions of Approval/Reasons for Disapproval <br />APPROVED.. er ^ r -W @ I I a-- 17n� <br />NONE 0 II-. <br />JUL 10 2018 <br />SBD -6398 (R. 08/14) <br />BURNETT COUNTY <br />ZONING <br />'G <br />00 <br />