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i :DI' Industry Services Division County <br /> 1400 E Washington Ave j }f'ue- <br /> (=i ap5 P.O.Box 7162 Sanitary Permit N ber(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> ., _- SAID-D.6-64 <br /> Sanitary Permit Application State Trans actionNu6X3`m�ber, <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit I � <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(I)(m),Stats. f I/'//Di <br /> I. Application Information-Please Print All Information 70 z <br /> Property Owner's Name Parcel# <br /> ✓ #/� / )t2o3a <br /> f�i m deo/5wf4J %N5 f' 67-+0314 4//-/6 27-/G 1r-000-opeto <br /> Property Owner's Mailing Address Property Location <br /> ac' #4,) 1/44` . ` <br /> Govt.Lot <br /> City,State Zip Code Phone Number /; 27 <br /> /� /�, Section <br /> /f/L ///N 5"S( Z //�� Circle one <br /> T 7 N; R f f j E a� <br /> II.Type of Building(check all that apply) Lot# <br /> t5rI or 2 Family Dwelling-Number of Bedrooms Z Subdivision Name <br /> Block 4 <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number, 0 Village of <br /> V3 / //tt Town of '5�/�lJ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System St 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 PlumberList Previous Permit Number and Date Issued <br /> 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> i"Non-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(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 360 . 1 qz9 y90 r %,6 te '9/4 i <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units t <br /> New Tanks Existing Tanks w u `' 'o <br /> E N <br /> n O in , in C7 i% <br /> Septic or Holding Tank 75-0 I j / / ,/ r X <br /> Dosing Chamber //�'i7✓,/�[{I/,�fJ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Per's Name,(Print) Plumber' nature, MP/MPRS Number Business Phone Number <br /> Atm T hay � �i evgs2/ 7/5-fg-a20-z <br /> Plumbers Address(Street,City,State,Zip Code) <br /> 6 8f AM At Ile i / we6571-er L/.• 5111393 <br /> VIII.County/Department Use Only <br /> 'Approved 0 Disapproved Permit/� Feed Date Issue uing gent Signori' / / <br /> • 0 Owner Given Reason for Denial $✓� �• SA,���� <br /> IX.Conditions of Approval/Reasons for D•sappr val ((( <br /> 5j l iivt cici I%44 + %.e 50ti' 4nrwt Welt <br /> Je Qoteit4e. sdb. ks man- bc tet. RECEINI <br /> la,z's'Ftw 46 kw. to et.Aece per SPs. 383. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 X 11 inches 1 <br /> MAY 1 9 2020 <br /> — Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br /> — <br /> W gQ518 4425. <br />