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„,r8I. "Err^ Industry Services Division County z/ <br /> s 1400 E Washington Ave <br /> $ z P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �,� ral Madison,WI 53707-7162 2 'r -,2,6_ 134- <br /> Sanitary Permit Application State Transai tion Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit b2311471 <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 <br /> I. Application Information—Please Print All Information 28788 �/1614,V re t <br /> Property Owner's Name Parcel# <br /> i'eg 4atrikti C04241/460.43-5-XV/4/-11000 <br /> Property Owner's Mailing Address • Property Location <br /> Pic M 2e4 lel/er 1/- Govt.Lot <br /> City,State ZZiipp Code Phone Number /, '/, Section 3 <br /> 4, 4,1 e,il ✓ V/� T 96 N R /e clEe oone <br /> H.Type of Building(check all that apply) Lot# <br /> 4 1 or 2 Family Dwelling—Number of Bedrooms Z 80 CI-8/ Subdivision Name <br /> Block# <br /> 0 Public/Commercial—Describe Use <br /> 0 City of <br /> 0 State Owned—Describe Use CSM Number 0 Village of <br /> JO Town of 744k04=6IJ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System '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 /> 0Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 5rNon-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil ❑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 Areatem Elevation <br /> 30° . 7 ylt A/410 Proposed(sf) System <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o ”' <br /> New Tanks Existing Tanks . a y 0 ro m <br /> aU v vo ir. C7 i;.. <br /> Septic or Holding Tank +J/1l 75 / ,�,2 V <br /> Dosing Chamber LL/O !J��/ 540 �Wte littler J� X <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Pl er's Name(Print) / Plumber's S,t.qr.ture <br /> MP/MPRS Number Business Phone Number <br /> tom, 1//Q ft �� 86/952/ 7/5--fa-024Z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 688/ SW,-At 1 le ,/ kJ€ - LA' 5'/89 3 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee Date ysuell . ,Agen&Sign• re <br /> 0 Owner Given Reason for Denial $3 46. <br /> 00 <br /> O20 / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> b trigiN f idmmht bt 6.• led o fiat all :edema are talk <br /> u <br /> A lit i cover rr aneaR eler t 61644(4* <br /> II/ l�A5 <br /> 31i� K midi lx s a t! SeemAd wt 10x1 : t; � C 0 M L <br /> p 12 <br /> Attach to complete plans for the system and s mit to the County only on paper not less Man 8 1/2 x 11 Q n sizeill <br /> JUL - 6 2020 <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br />