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1 <br /> �rAKY.. , Services Lim <br /> 1400 E w Ave County E <br /> kkg)SE TT- <br /> �,� $ h� P.O.Box 7162 S Permit Numbc x(to be filled in by Co.) <br /> y% _ <br /> Madison,WI 53707-7162 5R"N-20 n <br /> Sanitary Permit Application Stade Ten Number <br /> In accords's=with SPS 383.21(2),Wis.Adm_Code,submission rifts form to the appropriate gover unit <br /> t '"Tr ��✓ O <br /> is required prior to obtaining a sanitary permit Note:Application flaws for stato.aWood POWTS are submitted to Project Address(if different than mailing address) <br /> the Department ofSafety and Professional' Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s 15.04(1Xm),Stats 2.s SVLA ell A. -I-I. Applieabi ea Information-Please Print AB Information <br /> Property Owner's NamePar <br /> ; cel# 07 OlZ l--1,l0-I-5.% "5 <br /> .bi�-A�E KAY 5trt1M-A►,� 0S ON-tile_� <br /> Property Owner's Mating Address •Property Location g 53�4 <br /> 214 35s- ESQw► *SLUD. Govt Lot Si <br /> City,State Zip Code Phone Number ys v, Salton $ <br /> Fo' ST L/ccE, IV O23 6;1Zy 599'YI D T IA) N; R ) "'C') <br /> IL Type of BanydiaS(cheek an tint apply) Lot# <br /> %I or 2 Family Dwelling-Number of Bedrooms 3 - Subdivision Name <br /> Block# N A <br /> 0 Public/Commercial-Descnbe Use 0 City of <br /> 0 State Owned-Describe UseCSM Number 0 Village of <br /> /21 Town ofs-- 1614-SCA) <br /> III.Type of Permit: (Cheek wily ewe box an line A. Complete Tore B ifapplicable) <br /> A. <br /> 13 New System %Replacement System 0 Trentutentalokling Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B• 0 Permit Renewal 0 Remit Revision 0 Qange of Plumber 0 Perk Transfer to New + List Previous Permit Number and Date Issued <br /> Before Expiration Owner A� 1A <br /> IV.Type of POWTS S (Cheek all that apply) ""'\ <br /> Nm-Prt need In-Ground nd 0 Pressurized In-Ground ❑At Grade 0 MMMound>24 in.of suitable soil 0 Masai<24 w.of suitable sold <br /> /0 Holding Tank 40d=Dispersal Cotmgmnerg(explain) pVL .7� to ytt� 0 Pretisahn®t Device(explain) <br /> V.Dirpe salt Tteadaest Area Information: <br /> Design Flow(gpd) Design Sod Application Rats(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) Systrm Elevation <br /> h/.) ap 7 _6.42_ &5Z- 93. ` <br /> VI.Tank Info Capacity in Total II of Manufacturer <br /> Gallons Gallons Units so u <br /> Tasks New Existing Tanks s c V s. l� Ta <br /> a.ti m m co Cc. 'V a. <br /> SepticrnlieleirgeTwa <br /> hone" r.ec0 wi ..x <br /> Alosharanntin - <br /> Lit'," <br /> VII.Rea : icy Ste-1, d1 the enig.e#, , Lim... W <br /> , ,far fa9Ma <br /> at:a..f the POWT'sys ea tie *tacied plus <br /> Plumber's Name(Print) Plumber' ; !'T MR414~lumber Business Phone Number <br /> CORY- ZfeKSOAJ5 24 331 7r-&6�- `e'f <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 93ek, -e %K BROOK12-1),) W i3 sate cw'- siisto <br /> Vm Con.ty/D partme.t Use O ly <br /> / ed p Penns <br /> 3 Sit Fitxee 7A8cato4A,=e ./../tvt.,1/4._____,....._ <br /> 00 relssuA.02.0 <br /> (/ 0 Owner Given Reason for Denial <br /> IX.Cesddaaas of for Disapproval <br /> APPROVED izEovE � <br /> Amnia b e plias aha thr , . <br /> t ;t taeieh 2 0 2020 ry <br /> apnea aril aitit m Or Gamy m s4er art lets tiro rut A <br /> Burnett County <br /> SBD-6398(R.08/14) . -�F o_s Dep---.Sent_.— - <br /> 'P 4as° �'- -*LP5Lf0 <br /> Ja,c, err.. Pio",nam;Lf) <br />