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f:-w , County <br /> Industry Services Division <br /> ; r�. if) 1400 E Washington Ave S itary Permit Number(to be tilled in byC/o.) <br /> '1 $� 1 P.O.Box 7162 �QN - 19-2� <br /> ''y Madison, WI 53707-7162 <br /> C' -Iq fg` <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 5'3 7(4, <br /> purposes in accordance with the Privacy Law,s.15.04(i)(m),Slats. e <br /> I. Application Information—Please Print All Information !mot nos '' �za <br /> Property Owner's Name Ile Parcel# 5— /.S <br /> Jaw+eS v'be,--f- p7-o36--A 577 17 <br /> 6A0000 y.25'-1 3 <br /> Property Owner's Mailing Address /� Property Location <br /> 6,30 N w1 S'f, /apt I o O Govt.Lot <br /> City,State Zip Code Phone Number y, y,, Section 3 6 <br /> 5-WI W t,f-e✓ /" N S3_0 8.� cucle one <br /> R.Type of Building(check all that apply) Lot# T Z/ N; R 1 E or <br /> I <br /> 1 or 2 Family Dwelling—Number of Bedrooms ¢ /7 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> N Town of (40?O k <br /> II1.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ❑ New System �Replacement System d <br /> B. ❑ Permit Renewal ❑Pen-nit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: (Check all that apply) <br /> VN:on Pressurized ln-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.Dts ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(st) System Elevation <br /> 300 o S ao <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> Y y <br /> New Tanks Existing Tanks u <br /> 2 cn iL C7 a <br /> Septic or Holding Tank 7 5`O <br /> Dosing Chamber.. 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 Signatu e// MP/MPRS Number Business Phone Number <br /> �A5-5,5-/ ?/s- <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77G o /4 y 3-� W e b sfe•— <br /> VIII.Coun !De artment Use Only <br /> Approved ❑ Disapproved Pen-nit Fee Date Issued Issuing Agent Signa <br /> oc I� <br /> i N A DO I Q qA4Q <br /> El Owner Owner Given Reason for Denial t � �� � I <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ro/z-7 83 <br /> Burnett County <br /> Land Services Department <br /> 5g63 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size <br /> SBD-6398(R0313) <br />