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1 i7', \ County <br /> ..+ � <br /> �,�, � �. Industry Services Division f�G..v'N+e'� <br /> ,!i; al- 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> j5t 1 P.O. Box 7162 i\j-20 —1 Oa <br /> 'v••_ �'.. 7x. Madison, WI 53707-7162 cJ <br /> C$-(--..20 LDS <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (02.7113 . <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 secondaryc9 5 3 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. RoeL Application Information-Please Print All Information peit✓'So n <br /> Property Owner's Name Parcel# /01-- OO ) <br /> el_ cid-d-39-i6"�` <br /> Jasoti Hempel e/1700 <br /> Property Owner's Mailing Address n Property Location 3563+ <br /> 3a "Rl d e. woe!!" Pve Govt.Lot <br /> City,State Zip Code Phone Number y /,, Section ..1,04 <br /> S AA rt..- yr, Iv SS-67 Li (circle one) <br /> Ii.Type of Building(check all that apply) Lot# T 39 N; R 3 i or® <br /> tg,I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use <br /> ,® Town of Metvo.i <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. S <br /> �:New System <br /> ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B• ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber <br /> ❑Pennit 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 /> XNon Pressurized in-Ground ❑ Pressurized In-Ground ❑ At,Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) ❑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(st) System Elevation <br /> 300 . .5-- c6 600 5s= 7 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 2-2 o L - <br /> New Tanks Existing Tanks c o cnv ti rnY , a col.' a." <br /> Septic or Holding Tank .24M .5)4/0 /q J <br /> Dosing Chamber.. . co D 5".0.49 / 11 /e5 ed/ ) ),, <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature NIP/MPRS Number Business Phone Number <br /> IC-(L //49k.I n 5 7a•�G-ffez s./'ur �� oUiSBs--/ 7...r-?- 60-e-//5- 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> l 776,o //..7 3f (y�6s, .� h Z 5L7.9 7 3 <br /> III,County/Department Use Onlyc .e <br /> j <br /> Approved ❑ Disapproved Permit Pee <br /> $36°�� Dat [ss ed <br /> �p// /247.0 ssu Agpnt ugna[ure / <br /> ❑ Owner Given Reason for Denial ' <br /> IX.Conditions of Approval/Reasons for Disapproval ei <br /> 4,'a,. Sever.+' i. be iwkdate a if fiaiurc. sM4c#rire K 1.41- 1 <br /> f(Seasev444 w JUN 1 7 2020 tJ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in a l l i be I size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(80313) e II _tr_ t ci --Ir t_ et cJ•IG.'' <br />