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N. <br /> /,i7' ' T;.v County <br /> ' ' : "J Industry Services Division i3tnrnt ' <br /> l r:.:.s;f :.: '�. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> • ,,,:,! :.i')':','' !moi P.O. Box 7162 �!1^' 2D,Ileo <br /> =fg 1 ` syr,, Madison, WI 53707-7162 T'1'" eC "� <br /> State Transaction Number <br /> Sanitary Permit Application 40237.17/.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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. V <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 11�� <br /> 07_0A0),-Lit)--/6-3.1-41-o/'"C3 o0 <br /> Corf�te, lie er1�IG - Cyt1001 <br /> Property Owner's Mail g Address Property Location 'ft 32o6 <br /> G. 7577 SfbNG 6.afei /-2i' Govt.Lot <br /> City,State Zip Code Phone Number , <br /> /, /, Section 3.3 <br /> Web.s7 rer Lv-1- S`- -.3 (circle one <br /> T y0 N; R /6 -E ot�! <br /> II.Type of Building(check all that apply) qq Lot# <br /> / <br /> ® I or 2 Family Dwelling-Number of Bedrooms , 7 Subdivision Name , <br /> Block# <br /> ❑Public/Conunercial-Describe Use ❑ City of <br /> CSM Number El Village of <br /> ❑State Owned-Describe Use <br /> V 14 1'D 107 ®Town of pa/C 44 el(1• <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' LI New System y g Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.T.ie of POWTS S stem/Com.onentlDevice: (Check all that a,el <br /> Pbran Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Efoldm=Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V:Dispersal/Treatment Area Information: <br /> Design Fldw(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 . "7 lids 71-5-0 ,3, F 4/ <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o .� <br /> U <br /> New Tanks Existing Tanks <-1 Y a "ca' <br /> aon.) cn ti vt wC. . <br /> Septic or Holding Tank G O iii <br /> Dosing Chamber_ O 1 <br /> / f r-S se .) <br /> .coO5`00 1 <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /2 i G /c /L(a p lc,•, s /2 4/ xs-esr 7/s- , L-vls7 <br /> Plumber's Address(Street,City,State,Zip Code) i <br /> oZ 7 7 60 / t/2SI4ielsA-r .5-77L e9.y <br /> VIII.Coun /De.artment Use Onl / , <br /> 07 <br /> proved 0 Disapproved Permit Fez Date[ ue Issuin: A e ' For <br /> ,.� 1 azo <br /> CIOwner Given Reason for Deniale, 4, /31 <br /> IX.Conditions of Approval/Reasons for Disapproval -� i� 3441 5- <br /> * 17ra.mcit to( wtA4. f. e at or *Jowl. 9320.4 E c E ll v E -. . <br /> id ais4441 SIOsfuwl. 45 i.c al a�o�wo4ot par S 3$3, D <br /> 1 <br /> .. 1 % . e. L. N. I , 'rN 7t'H. JUL - 8 2029 /' <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 ll?s 1 tuck sin size / <br /> Burnett County — <br /> __/. <br /> SBD-6398(R0313) r , Land ServioesOppggnent <br />