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"': Industry Services Division County <br /> '`? D 1400 E Washington Ave U1rwe f <br /> + ; ti.\s p P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> ;; r 6A1J-Xo-33 <br /> ,,-,: <br /> Sanitary Permit Application State Transaction NumberQ <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit ( ' 67 7 0 <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 Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. A /f <br /> I. Application Information–Please Print All Information V 7fD Q +//{,/,. <br /> Property Owner's Namef� leN/41 Parcel# It 42,70$ <br /> �`avA4 4�vOe N-02-2-4/147114 0.o+,-ev <br /> Property Owner's Mailing Address Property Location <br /> /04/ gWWW(iC Ceee)c Ci-( Govt.Lot <br /> City,State .�},� Zip Code Phone Number OA/ y,, f�' y,, Section 36 <br /> 1 ('V(/' / A1 �Q"�j WC u� mete one <br /> v v / T �7 N; R E ob <br /> II.Type of Building(check all that apply) � Lot# <br /> r I or 2 Family Dwelling–Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial–Describe Use ❑ City of <br /> ❑State Owned–Describe Use CSM Number 0 Village of <br /> [Town of 1W 4'55 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. I New System y 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision ❑Change of PlumberList Previous Permit Number and Date Issued <br /> 0Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> (TNon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(g-pd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> ?co . ? V 1 4/29 f2,,,Z <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o n <br /> New Tanks Existing Tanks v o g , 3 <br /> n 1,3 <br /> .. t..1 iz m rA iz (,Q ta. <br /> Septic or Holding Tank AMU a) / f /� A� 1 f/ <br /> Dosing Chamber ea) /^/r_V j <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) Plumber's S' • re MP/MPRS Number Business Phone Number <br /> Atm i 1/fay ��� %�2� "7952/ 7/5"-1g-6242 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> get vM z le ,I kle6s/er L/1' 5t/&9 3 <br /> VIII.County/Department Use Only <br /> /�pproved ❑ Disapproved Permit Fee Date7/4,(A.0.1.0.0.4 <br /> 00 ti sue g en e <br /> — <br /> 0 Owner Given Reason for Denial $ <br /> 35: a 240,0 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> it iltis peewit- i6 ovtit'f Volt e f r a resiGtCl�FiaL S n cturc/ /' <br /> i <br /> J4 .1 becol4ceb 1)1.41k/cow tuerc icL 'the fta+C 1.44.440 06 44 <br /> +kt siistekAA, Ps si:eot apprn pr;0.1ei . 'L © C ll M 1 `11 <br /> Attach to complete plans for the system and suD nit to the County only on paper not less than S tax It n t in <br /> APR 9 2020 1U <br /> SBD-6398(R.08/14) <br /> Burnett County <br /> Land Services Department <br />