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Industry Services Division county. <br /> 1400 E Washington Ave �. <br /> P.O Box 7162 � <br /> 1~ Sanitary P it Number(to be filled in by Co.) <br /> Madison,W153707-7162 <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 emit ?zJT3 — O.S/ 9e04Z 9 C- <br /> is required prior to obtaining a sanitary permit.Note.Apphication 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 /> _Lurposes in accordance with the PriM Law,s. I5.041 ! m Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name <br /> Parceh# �� <br /> G�l� <br /> Property Owner's Mailing 70141 <br /> Property Location <br /> City,State � f Zip Code Phone Number Govt Lot--�-}— <br /> R Section <br /> y �Ie onP II.Type of building(check all that apply) Lot# T N; R__1_�__E o W <br /> `fit 1 or 2 Family Dwelling-Number of Bedrooms L� Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> Town of!- �► )� <br /> III.Type of Permit: (Check only one boa on Pane A. Complete line B if applicable) <br /> A. ❑New stem S <br /> Y Replacement System Q 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.T ype of POWTS System/Component/Device: Check all that a <br /> Q Non-Pressurized In-Ground ❑Pressurized.In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil $,Mound<24 in.of suitable soil <br /> ❑Holding Tank Q Other Dispersal Component(explain) - ❑Pretreatment Device{explaim) <br /> V.Dis ersal(Freatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required s Dispersal <br /> p eq {f) Area Proposed System Elevati <br /> Tank Info a Capacity in / Total �#of ! G, <br /> Mamufactha tuer <br /> Gallons Gallons Units <br /> O U <br /> New Tanks Existing Tames _ ?� <br /> 3 $ <br /> Septic or Holding Tank ',� a to va ri C7 P, <br /> Dosing Chamber G G <br /> VII.Responsibility Statement-i,the undersigned,assume responsibility for instalhatiou of the POWTS shown on the attached plans <br /> Piu s Name(Print) Pitanber S" ature MP/MPRS Number Business one Number <br /> Plumber's Address(S City,State,Zip Cade) <br /> VIII.Coun /i?e artmettt se <br /> ❑Approved Q Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> ❑Owner Givers Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APPROHO"kAttach to complete plans for the system and submit to the Co"my only on gaper not Tess than 8 in z 4 slsa <br /> MAY 1 3 2019 <br /> uu <br /> SBD-6398(R.08/14) Burnett County <br /> �/ Land Services Department <br />