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4V-'=""� Industry Services Division County <br /> 1400 E Washington Ave �U ( <br /> ic` <br /> I , <br /> isl -, s P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �, p$ Madison,WI 53707-7162 <br /> n, 1 ^O -3 ' <br /> State Transaction Number <br /> Sanitary Permit Application (�zo�88 <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <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. /O ar C./�'�J <br /> I. Application Information—Please Print All Information 78J 4w/44 <br /> Property Owner's Name Parcel# tfa(0518 ' <br /> 77/17 41)Aidi d7- 1 Z eiB .5`SOF"aD3—©(3QO <br /> Property Owner's Mailing Address'j [�J� //� Property Location <br /> 321l V lel it Govt.Lot <br /> City,State( t ip Code Phone Number <br /> ' y,, %,, Section Z� <br /> /I�Lyi 5 �/V ��Q)3 6✓!'bt/✓ /Z T 32 N; <br /> R / 'eirclE o) <br /> II.Type of Building(check all that apply) Lot# / <br /> itr I or 2 Family Dwelling—Number of Bedrooms 3 y Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number/ ,.�(/ ,/,. 0 Village of <br /> V i l/l"i(Nr/1�.l zzA. �Toµm of ��/'r <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other 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 Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade ($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(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(SD System Elevation <br /> 50 i <br /> 14 , <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> 4,2 <br /> New Tanks Existing Tanks v c t, , y t. A <br /> 0 r. <br /> C."U in 7, rn u. 0 n. <br /> Septic or Holding Tank 000 <br /> Dosing Chamber Loo P y ikd(&) X <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) i Plumbs s gnaturr MP/MPRS Number Business Phone Number <br /> Vfall /40-'4/48 /95 /' 7/5--sv-624Z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6 8( Awl-Ai L e ,/ (A1e6 c,✓t' 5y&9 3 <br /> VIII.County/Department Use Only / <br /> pprovcd ❑ Disapproved Permit Fee Date sue ting A ent Sigt�atur <br /> 0 Owner Given Reason for Denial $a 7 d • A) 7 a 20a0 <br /> IX.Conditions of Approval/Reasons for Disapproval , / <br /> k All Co i $talc YtivAirelllL4C&L S Atigrf lot wtF, <br /> pit Mast 10, A. iacll, river, mut /alta,• E © E 0 V E ' <br /> (r)r c cid) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 IR s Pt S in size <br /> APR y 2020 J <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br /> co-Ape- 1'/ <br />