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•',it'g�'T,.� County <br /> Industry Services Division <br /> d. 9 Sanitary Permit Number(to be filled in by Co.) <br /> 1400 E Washington Ave <br /> P.O. Box 7162 J '«o <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 1 q" t <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 infonnation you provide maybe used for secondary <br /> purposes m accordance with the Privacy Law,s.15.04(1)(m),Slats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> off.• Cr1 S.L-rho-14f-Ao S'! <br /> /ya Ss/1i A h �f{s Oa 1.4 4Atee t-ar►., of 9ouo *191go <br /> Property)Owner's Mailing <br /> Mailing Address Property Location <br /> /A YJ—! (:fO Ae / 1 Govt.Lot <br /> City,State Zip Code Phone Number y,, %, Section -4 O <br /> s �7 ���' circle on <br /> II.Type of Building(check all that apply) Lot# T y� N; R E or <br /> �I or 2 Family Dwelling-Number of Bedrooms 7 4 0 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑ <br /> El State Number Village of State Owned-Describe Use �y -/L <br /> V. f ! P .4-76 Z Town of 56 Tr <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Iv[oditication to Existing System(explain) <br /> New System p y a <br /> B. El Permit Renewal ❑Permit Revision <br /> ElChange 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 ap I ) <br /> ❑ NFdn Pressurized In-Ground ❑ Pressurized[n-Ground ❑ At-Grade ❑ tv[ound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> I folding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks c A ca W <br /> Septic or Holding Tank s`O �O (•Nr! fir <br /> Dosing Chamber.. <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 SSignaa e MP/MPRS Number I Business Phone Number <br /> Z161C f e /4n <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7 70 6 L e,ez v T 7 3 <br /> VIII.Coun epartnient Use Only <br /> proved ❑ Disapproved Permit Fee Dat [ssue mg gent SiTe <br /> $ 00 <br /> Q <br /> ❑ Owner Given Reason for Denial /� 2�- ��� O <br /> IX.Conditions of Approval/Reasons for Disapproval (= (J M <br /> APPROVED r <br /> AUG 2 1 2019 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x l l in s i ile <br /> Burnett County <br /> SBD-6398(R0313) Land Services Department <br />