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0 <br />l <br />Safety and Buildings Division <br />201 W. Washington Ave., P.O. Box 7162 <br />County <br />u!N <br />seonsin <br />Madison, WI 53707 — 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />Department of Commerce <br />(608) 266-3151 <br />,w 10 <br />Sanitary Permit Application <br />State Plan I.D. Nu <br />In accord with Comm 83.21, Wis. Adm. Code, personal information you provide <br />may be used for secondary purposes Privacy Law, s 15.04(1 Xm) <br />Prod t Adders (if different than mailing address) <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel #7Lot # Block # <br />07 1- Wit- 15 = Jb - z <br />Property Owner's Mailing Address <br />Property Location <br />f G <br />'/., %., Section <br />City, State <br />ZipPhone <br />Number <br />NV� rove- &• N <br />`Code <br />6�✓Q7� 6Jr�' <br />15OJ'406? <br />��// �+roleynejt <br />T 7UN: R f J Eor <br />11. Type of Building (checfi all that apply) <br />�y 2 <br />t[.rl or <br />Subdivision Name S umber <br />❑ Public/Commercial — Describe Use <br />t 4/11 <br />❑City Village gyyatship of <br />❑ State Owned — Describe Use <br />111. <br />Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />New System <br />y <br />❑Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />El Other Modification to Existing System <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />Owner <br />IV. T e of POWT3 System: Check all that apply) <br />rNon —Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ <br />Constructed Wetland ❑ Pressurized In -Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ <br />Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) <br />V. Dispersal/Treat ent Area Information: <br />Design Flow (gpd) <br />1 <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (sf) <br />1 <br />Dispersal Area Proposed (sf) <br />1yZ9F <br />System Elevation <br />- - <br />3w <br />. 7 <br />#Z1 <br />9z.s <br />V1. Tank Info <br />Capacity in <br />Total <br />Number <br />Manufacturer <br />Prefab <br />Site <br />Steel <br />Fiber <br />Plastic <br />Gallons <br />Gallons <br />of Units <br />Concrete <br />Constructed <br />Glass <br />New <br />Existing <br />Tanks <br />Tanks <br />Septic or Holding Tank <br />Aerobic Treatment Unit <br />Dosing Chamber <br />VII. Responsibility Statement- 1, the undersigned assume responsibility for installation of the POWTS shown on the attached plans. <br />Plui ber's Name (Pjr'"t) <br />Plumber' ature <br />Number <br />Business Phone Number <br />5 /o%/Q�c+lttr� <br />TMP/MPRS <br />4� 9-4 7 <br />7/5 =Ti t�- oaoz <br />, State, Zip ode) <br />Plumber's Add=1/4� <br />G 1 Wtb 1&- w• k g <br />VIII. Coun !De artment Use Only <br />17pproved <br />❑ Disapproved <br />Sanitary Permit Fee (includes Groundwater <br />Date Issued <br />Issuing Agent Signature (No tamps) <br />❑ Owner Given Reason for Denial <br />Surcharge Fee) 3 .7 S: <br />6 ' Z/ ' <br />L <br />IN. Conditions of Approval/Reasons for Disapproval <br />CC�LEOMC <br />APPROVED <br />R1 <br />JUN 19 2019 <br />�+uacu coanprcre puns tea in ry omy) ror the system on paper not less t n a12 x l l me in sa ' <br />L- Burnett County <br />S�QCt fief ,°' Land Services Department <br />SBD-6398 (R. 01/03) G - 74 <br />;P440 <br />