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inuusuy Nemces Division County <br /> 1400 E Washington Ave <br /> .,. <br /> ,.. <br /> , :.. s ,:,. <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 Sictio-At) -32 <br /> ._,. <br /> Sanitary Permit Application State Transaction Number <br /> In ai.,-..ofclatice with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 623109 <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 Senices.Personal infaimation you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,S.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information <br /> ‘-t--Psi t: <br /> Property Owner's Name, <br /> Parcel 4 tj Pa&I <br /> 02.4-9z-oo -0,1"0 a <br /> Property Owner's Mailing Address <br /> 5 <br /> Property Location at..t yt . <br /> Govt.Lot <br /> City,State <br /> Zip Code J Phone Number <br /> iv‘,,,..) l/.1,0"-t Yt, Section 1 9 <br /> 745-.1 t.t -117 V , (circle orA <br /> T Y 0 N; R /b. E 6.ye <br /> I H.'J),pe oluilding(check all that apply) Lot 4 <br /> 2/-LZ.-2 5 <br /> Subdivision Name 9f.t.‘71-,....,/.1 /...fle'C <br /> •e-i or 2 Family Dwelling-Number of Bedrooms 3 <br /> Block 4 TA Vi V. Vtlic ni 44 je„:.e <br /> 0 Public/Commercial-Describe Use <br /> 0 City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of <br /> Si Town of Cl?kict 1,) C/ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 Nev,System 0 Replacement System 0 Treatment/Holding Tank Replacement Only lZher Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration <br /> Owner V8.377 7... /--i--) -- 6 <br /> 117.3.),pe of POWTS System/Component/Device: (Check all that apply) <br /> .„.r.-1 Non-Pressurized In-Ground 0 Pressurized hi-Ground 0 At-Grade D Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> 0 Holding Tank D Other Dispersal Component(explain) D Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate I Dispersal Area Required(if) I Dispemal Area Proposed(sf) 1 Sy •m Elev o <br /> '75Z) i , -7 1 (...V 3 I 7 2-0 1 ci• . 4 i 9" <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units <br /> -F2 R t3 7) . .9 <br /> New'ranks Existing'ranks <br /> 4 ' =1 " 1,p-, c.) 65 -,-4 no <br /> Oti or Holding Tank <br /> 32-o 800 1110 2- 5-if cc., le I <br /> Dosing Chamber <br /> I Ii <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS slu9sw4son the attached plans. <br /> ber's Name(Print <br /> Pc-714/ av-4;it-s <br /> .....ii <br /> PI mber'i Plumber's Signature .M1) <br /> (7 ,,N.Number 1 Business Phone Number <br /> Address(Street,City,State,Zip Code) <br /> L ',Ad Yg.f3 <br /> pproved 0 Disapproved <br /> County/DePartment Use Only <br /> 0 Owner Given Reason for Denial 1 Permit Fee Date ane <br /> $ 345 00 5 v Ao--2.01 <br /> VIII. <br /> —.._ <br /> IX.Conditions of Approval/Reasons foro=rov.al wow. 95 8c4. <br /> it -praialwd a vakiovt be ok of <br /> 141145Apecka VkAA.14+ bc 5C+ frow. propel/4y thAt. <br /> 'H © <br /> tAksAv be- (vice- <br /> iL---7 ir------1 ------/ I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 inehei iti sie ,, <br /> 1.1 MAY 4 2020 IL)/ <br /> 1 <br /> + 1 <br /> i — Burnett County <br /> SBD-6398(R 08/14) <br /> 1 _ Land Services Department <br /> 4!. 315°° 02>" q4 D' <br /> ti-A.W k-.4 S (i).vr e 47.eSirh-r-t\------ <br />