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y c s.j� County <br /> raj -4-s, /vj <br /> 1.,` - Industry Services Division u y el e - <br /> I{D'� >, rl <br /> . 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> -,s P.O. Box 7162 �p� <br /> s f-' SAN—,'0-!4 <br /> Q; •,,7. Madison, WI 53707-7162 <br /> 'C��i7— >13b <br /> Sanitary Permit Application StateTra°Sa/c`i°nNmmber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit I4 Z83oz. <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 of 9 3-7 Li <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. <br /> I. Application Information-Please Print All Information L.on7 f/ayden Lh <br /> Property Owner's Name Parcel# vo„/6-.0 y-S'..- /,-- <br /> hi Ay-14- 0 w b a/-c <br /> 07-0'010 <br /> a- <br /> y3S- O/6 bat, <br /> Property Owner's Mailing Address Property Location 414141 <br /> 6 scot 6 cia,,-ti Govt.Lot <br /> City,State Zip Code Phone Number11/ <br /> / /, /<, Section <br /> Cd?`/1RSi� Greve N 5'6 I yo T y° N; R / (circleoone� <br /> II.Type of Building(check all that apply) Lot# / r(�V/ <br /> l ort Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Cornmercial-Describe Use <br /> ❑ City of <br /> CI State Owned-Describe Use CSM Number Village of <br /> 3Leo95-1 ®'Town of 04kiAv)i- <br /> n Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. X New System y ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. <br /> U .Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑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 /> 9'Non Pre$si iized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ 1-bldmgTank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dispersal/Treatment Area Information: <br /> DesignFloW(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 'iso • 7 (Lj3 el8 9l,5- <br /> VI.Tank Info Capacity in Total #of Manufacturer t. <br /> Gallons Gallons Units o 3 o <br /> .n N <br /> New Tanks Existing Tanks w U 1 y 5 <br /> aU my CO I-LV a. <br /> Septic or Holding Tank ,6 D b //O O D / 1/v /'CjlT v Y <br /> Dosing Chamber.. i -. <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 <br /> !/ MP/MPRS Number Business Phone Number <br /> (2 , G i`/B , r /Citi4a�,S / 7..5-.0' ) - 9/,s-7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> J7760 bit, , ,;s 1eve4s711.-,- r, 'f 5-z748,y <br /> VIII.County/Department Use Only <br /> Permit Fee Date sued .ssumg _ent Sig-nature <br /> pproved ❑ Disapproved $ 3�•� 116 <br /> ,J � b / <br /> ❑ Owner Given Reason for Denial .-r . <br /> IX.Conditions of Approval/Reasons for Disa proval i:4";r,:';(IS.lInlitai <br /> #11. <br /> iE Bins to . parer . tD c c ced 3. wtiess 'WT5 it s (j E © E ii d i -- <br /> IAj scats e. , <br /> *pactskcic a midi- k•G l Lake trod all wells, JU ___02 —I <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 inn 1s i lie <br /> __ <br /> Burnett County <br /> SBD-6393(80313) Land Services Department <br />