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_,-`-'(.. 3;-„, Industry Services Division County <br /> 1400 E Washington Ave VO/d,- <br /> i ._\s p - P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> 5 Madison,WI 53707-7162 SAN_.20 1 4 1 <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (023ns <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. <br /> I. Application Information-Please Print All Information 29 Zo VG ak`A/li is <br /> to <br /> Property Owner's Name Parcel# �,p 7 <br /> a0 N Kin), 0740704-110.46.42-S 06-oo/-0/7000 <br /> Property Owner's Mailing Address �jProperty Location/ <br /> Yd <br /> /7720 V .4 j W'qy #1 <br /> - Govt.Lot 7 <br /> City,State p Code Phone Number y,, %,, Section 2 <br /> k/'f/ ll!�'e/, ft 339/y 647-y15"-6/e S -I/O N; R �j/jcircle one <br /> T E or <br /> II.Type of Building(check all that apply) Lot# <br /> Fri or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> (S Town of D!f yk/Vd <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System YReplacement 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 Plumber 0 Permit 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 /> ❑Non-Pressurized In-Ground 0 Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> M" 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(s0 Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units s, o'- <br /> New Tanks Existing Tanks w e u rd .2 3 R <br /> o h <br /> 8: L., � � ix. V a <br /> Septic or Holding Tank 'Oa' Zt l�/.-- y L V y/ <br /> Dosing Chamber 7 <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) / Plumber's Si a c . � MP/MPRS Number Business Phone Number <br /> t l//Q/d€ /0".. `'.t 85/9 52/ 7/1--.5-0-ceoZ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 668/ ,v� w Lie // 1iJe6s u.. 54/69 3 <br /> VIII.County/Department Use Only <br /> pproved ❑ Disapproved Permit Fee Date sty ssuin nt Signa e <br /> -$ ,� / 72ozo <br /> 0 Owner Given Reason for Denial <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> so Tawk O ctlat be pithy[ : *alai pee Slo • 3$e 102 2 .51-.51-3-23 <br /> 341autk ‘44444 be 44 P4144 4 6 tflArkffiS• M <br /> ED <br /> orxish4 steteLA {o bc, t,..wee prr SFS. 3$3 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t 2 x • t s in size <br /> JUL 092020 <br /> 1 <br /> Burnett County <br /> SBD-6398(R.08/14) <br /> Land Services Department 1 <br />