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a `''ry <br /> ..; County �L <br /> / ; : '`+„4 Industry Services Division Liu-en �/t <br /> 9i. <br /> ,ter D- WashingtonSanitary Permit Number(to be tilled in by Co.) <br /> S �. 1400 E Ave <br /> `` P.O. Box 7162 C(om�,,�tt <br /> '.,i Tk j Madison, WI 53707-7162 ��"v l 18� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Y/^� � <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 <Ic a�9J, 419 zti <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. Q 1 <br /> I. Application Information-Please Print All Information //Oil Xe r.' /ies lie w / d <br /> Property Owner's Name Parcel# tc•AS.mom <br /> Property Ow/ / <br /> Owner's Mailing Address Property Location <br /> Qo <br /> v ( (.. l t h i-s / �. Govt.Lot <br /> City,State Zip Code Phone Number /, y, Section 3 <br /> /T 6(s 0 h ti--2...G .'L+f D i b (circle one) <br /> U.Type of Building(check all that apply) Lot# T 90 N; R /y E or <br /> Z l or 2 Family Dwelling-Number of Bedrooms OZ )•,) Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> D2 Toavnof 5 c'W <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. pri <br /> Ai New System y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision LiChange of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTSSystem/Component/Device: (Check all that apply) <br /> jig Neon Prel tiized In-Ground ❑ Pressurized In-Ground ❑ At,Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ EioldingTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.-Dispers'al/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 30O • s' ceo loon • `ti-1, t <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .0 B o d2 <br /> New Tanks Existing Tanks ° en KI ac,u In ti rn cz.CD . <br /> Septic or Holding Tank /OSt <br /> Dosing Chamber.. j -)i <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 /> t2 e c AA /e/o /e a�f 2c.€. 41 4 :..s/ 7/� 06'q/5-7 <br /> Plumber's Address(Street, ity,State,Zip Code) <br /> 7? o 444._y 33- Gt✓e6s6 /-J---S-9e,3 <br /> VIII.County/Department Use Only i <br /> Permit Fee Date ssue. suing • :-nt Sign.ture <br /> r <br /> proved ❑ Disapproved / <br /> 1ry5 19 0 _ <br /> ❑ Owner Given Reason for Denial .77.0. r/ fes' / <br /> IX.Conditions of Approval/Reasons for Disapproval Iry V a12.311111111&&1N <br /> 4 ,local bi 44 dr above 9V./Olaf. iv <br /> 4J l bG SOF+ D AMCI. t, C 0 M G 1 <br /> 4iStrielei19#04.4Pelee Wast be (19 Goof, 4/1te17,4.6. <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 a II - .he r size <br /> 1 / —Burnett County <br /> SBD-6398(R0313) Land Services Department <br />