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T' re County <br /> Z5X Industry Services Division l�rN� <br /> . � 1 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box 7162 <br /> Madison, WI 53707-7162 <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 unit `-��6& <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project A dr s (if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary AD ,1 <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Slats. A"O(I rsov, //► t �@ <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel <br /> a�OS6`a_3/O 17 <br /> f -evt n 14 ogle s ©w6elo aso3 <br /> Property Owner's Mailing Address Property Location <br /> S-a qo W i m de m e Ire L✓i Govt.Lot <br /> City,State Zip Code Phone Number /, '/a, Section a u <br /> RL 'hs V °((e Mov �6rS3496 (circle one <br /> II.Type of Building(check all that apply) Lot# <br /> T yd N; R I� E o� <br /> 1 or 2 Family Dwelling—Number of Bedrooms d Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> 142 <br /> R ` JQ Town of <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑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.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Nqn Pressurized 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 /> 1. <br /> V.Dis ersal/Treatment Area Information: <br /> Desio Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> �3en , s� 600 600 qt.1 '?d <br /> VI.Tank In Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> ram+ VI <br /> New Tanks Existing Tanks P <br /> o <br /> g. q C.U rn h rn ii U a <br /> Septic or Holding Tank <br /> Dosing Chamber.. i <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWI'S shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/Ml Number Business Phone Number <br /> 866--Wr 7 <br /> Plumber's Address(Street,City;State,Zip Code) <br /> 76e Z+,�- <br /> VIII.Coun IDe artment Use Only <br /> proved ❑ Disapproved <br /> Permit Fee Date Issuear I esuing ARIVnt Signature <br /> ^ � <br /> ❑ Owner Given Reason for Denial $ 3?5 00 91161, <br /> � , 0' <br /> IX.Conditions of Approval/Reasons for Disapproval a <br /> APPROVED nni <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 s 11 inch si <br /> Burnett County <br /> SBD-6398(110313) Land Services Department <br />