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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 vrpeht <br /> �seonsin Maiison,WI 53707—7162 Sanitary ermit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 —14A <br /> 9 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide &I.o:nJ <br /> may be used for secondary purposes Privacy Law,s15.04(1 xm) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information L <br /> Property Owner's Name ��,// Parcel# v Lott## (� Block# <br /> 076 ��`� 7 azv-d-011-0z-So5'-oo2-0n 64 <br /> Property Owner's Mailing Address Property Location <br /> 6LI <br /> Z707 CGG Y., %, Section <br /> City,State Zip Code Phone Number <br /> [� trcl <br /> T 7a N, R�E A.W <br /> 11.Type of Building(eheck all that apply) <br /> ❑}or 2 Family Dwelling-Number of Bcdcooms <br /> Subdivision Name CSM Number <br /> Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Village WFo%vnship of Jg4Rk <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System <br /> y Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> I\T.Tv e of POWTS System- Check all that apply) <br /> QQ Non—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.Dis ersalfrreatmentArea Information: <br /> Design(gpd) Design Soil Application Rate(gpdsf) Dispersal Ar Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 7 67 /o7Z17M 69,51 <br /> Vl.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New cNiag <br /> Tanks 'Bde <br /> Septic or Holding Tank Z40 7W Z000 <br /> Aerobic Treatment Unit <br /> Dosing Chamber e4o ,06 <br /> VII.Responsibility Statement—I,the undersigned assume responsibility for installation of the PONYTS shown on the attached plans. <br /> PI u er's Name(Pr t) Plumber's i ature o , MP/MPRS Number Business Phone Number <br /> 91 X40 lae7 857��y 7/5-'ri o�- oZo2 <br /> Plumber's Address Street,City,State,Zip ode) <br /> G �nJ1/c V vek 1cf w ' <br /> VLII.County/ e artment Use Only <br /> pproved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date su WAgant�gi :alu�reop <br /> Surcharge Fee) Qb ( J7: <br /> ❑Owner Given Reason for Denial 3 ►d f� <br /> M Conditions of Approval/Reasons for Disapproval �"L L <br /> ' Alt c C�vtO�%tr'ovtS 70 67 <br /> $A& <br /> APPROVED E QD� rE 0 %# 1p= <br /> Attach complete plans(to the County only)for the system on paper not Jess than 81/2 x 11 inches in s Hn L nrl 9 2019 <br /> SBD-6398(R. 01/03) Burnett County <br /> Land Services Department <br />