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ano <br /> 13 <br /> V1 :.$' 201 Washington Buildings <br /> ve P.O�Sox 7162 g Ari l <br /> `��R' Madison,WI 53707-7162 an4�'Permit Number(to be filled�by Co:, <br /> 5.a.1-a0 -13 r <br /> tv — -a 15 X188 <br /> Sanitary Permit Application Sone Transaction Number <br /> e aero ce with SPC 3812I(2),Wis.Ada.Coda submission of this dim to Naekj c <br /> ddpgrt3pdYarc gaverndttentat unit ' T 5� �;_3r�o 4CJ 7 l 1 - c. <br /> n required prior to obtaining a sanitary permit Note:Application forms for state-owned POWTS we submitted to Project Address(if chi:leant than mailing adds <br /> be Department of Safety and Professional Servies. Personal information you provide may be used for secondary <br /> mores in accordance with the Privacy Law,a.13.04(l01).Stens. 29460eeiC gilt. <br /> Application Information—Please Print Mi Information <br /> 'roperty Owner's Name Patel d <br /> tela-u) e FI i1I *PR.0 io 07 -020 - 2-4/0 -it,�`1- <br /> 3roperty Owner's Mailing Address Property Location 0 i/66/ <br /> 1 dr' -0i cies-P2/rtl DC zl V jL yA Gert.Lot r i" Z tt 353V8 <br /> City,State Zip Code Phone Number `l., `A, Section <br /> "T A vvw-IA F L J 3 6 (circle one <br /> IL Type of Building(check nil that apply) Lot T yr� N; R/'CO E d>i> <br /> ❑ I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> Atublic/Commercial—Describe Use <br /> 0 City of <br /> 0 State Owned—Describe Use CSM Number 0 Village of <br /> &own of 0 A Iii ill V0 <br /> UL Type of Permit (Check only one box on line A. Complete line B if applicable) <br /> A' '`New System XReplacement System 0 Treatment/Holding Tank Replacement Only j 0 Other Modification to <br /> Existing System(expo <br /> IL 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date leaned <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device'. (Checks!!that applyl <br /> Nun-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 /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: I Q'U`i(IC 111 ? <br /> Design Flow(sal) Design Soil Application Rate(gpdsf) Dispersal AreaEl et k1V�' - <br /> Required(at) Dispersal Area Propend(:tf1 S m Eev <br /> I i3c430 _ ,--7 ic12-al 19e7 q i , r <br /> VL Tank Info City in Total N of 1 Manufacturer <br /> Gallons Units <br /> New Tanks Existing Tearer i CI 'din in �,i <br /> Septic or Holding Tank :5)06,V <br /> Dosing Chamber `� 1 v�i ( �L <br /> I <br /> VII.Responsibility Statement- I,the sad ,assume responsibility espoasfbility for las flea of the POoW7'S shown on the attached plans. <br /> Plumber's tante(Print) Pltz!7 ' heogPitS3lumber Btu Phot Num <br /> PI 's A , _ (Street,City,State,Zip Code) 7 <br /> 15 <br /> 0.: •p)L S6 iy .- nerd- to( SLIO9ejr <br /> VIIL County/Department Use Only <br /> ''Approved 0 Disapproved Penult Foee6 S" / / / <br /> 0 Owner Given Reason for Denial $350.°6 <br /> .2.158172.4920 <br /> IX.le +'sWrl��Gt;� �vaUReason:for Disapproval Le _ �a 1. �0 <br /> �.s�+� �v� midi btai or 0.4w6 91.Imo, C�, E [ �ICr' -wast be at Qeail fitei4C 1,2 ' <br /> Aroma to complete peat lar the system sod Montt to the County only on paper not loss aexii iakfks1tt�!e 2020 iSBD-6398(R. 11/1l) --Burnett County <br /> Land Services Department <br /> g‘, tioarkeTh fa <br /> .ei_t, G... <br /> 4iR._ aa.iJ •{- nttn4i <br /> � <br />