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N. <br /> Not Installed <br /> : *�; Count -1 <br /> g + Industry Services Division t.-y o,C41 <br /> ,5 r "' I R E D 1400 E Washington Ave Sanitary Permit Number(to be tiled in byCo. <br /> ,� P.O. Box 7162 541-�iy-�8' filled <br /> I- L. �/ <br /> itir l Madison, WI 53707-7162 (CCC����/ I <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 Servies. Personal information you provide may be used for secondary ?cA, -S' <br /> purposes in accordance with the Privacy Law,s. 15.04(l)(m),Stats. lfs ���f Q <br /> I. Application Information-Please Print All Information r� b <br /> Property Owner's Name Parcel# <br /> lee.vtvi 0 .6ilaild <br /> 000-0/300o <br /> Property Owner's Mailing Address Property Location <br /> pa ee K 3-6 9 Govt.Lot <br /> City,State Zip Code Phone Number / '4, Section 33 <br /> w,e 6s TY✓ l-1" H 3 circle one <br /> II.Type of Building(check all that apply) 3 Lot# T 4/17 N; R E o 4V, <br /> fiii I or 2 Family Dwelling-Number of Bedrooms 2- Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> I/ <br /> i (O P i/y g Town of QCr 6-/et>7d <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. *New System y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> — <br /> B• CIPermit Renewal ❑ Permit Revision CIChange 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 /> cYvon=Pressuriked In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding:Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> ys D j s— Tao 9cW Ci 3z <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units a -3 c, <br /> New Tanks Existing Tanks ti ° U y o v <br /> al <br /> c,U H c/3 Cr.O a. <br /> Septic or Holding Tank /0 bd /e0/ <br /> Dosing Chamber_ 640 �ei0 / V - j-eS ee X , J., <br /> VII.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 /> /?/C.-k 010k,v, /> -...-0 ii/ ds-3,5-i ? ,5' - 94 -7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> .277 ,o 7</wy . s' kV <br /> VIII.County/Department Use Only _ <br /> ❑ Approved 0 Disapprovedit ' , ge/n,�gnature <br /> "� fY <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval © E <br /> RE <br /> APR 1 8 2019 J <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 inch s in siz 1--- <br /> Burnett County <br /> Land Services Department <br /> SBD-6393(80313) <br />