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.-,!.g,;•27;4,-4!..„ County <br /> il r .:,:+ Industry Services Division �w.rn.eit- <br /> , t 0 '`rte 1400 E Washington Ave <br /> 9 Sanitary Permit Number(to be filled in by Co.) <br /> '1 P.O. Box 7162 Sj— —/57a,, ,r Madison, WI 53707-7162 <br /> t:.sr> <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 GLIA 313 <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 st,7 R pave O/ 4.14/Z/ <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. -1 <br /> I. Application Information-Please Print All Information e 2220 <br /> Property Owner's Name Parcel# ,S" <br /> 07-030t"61,yi—/b -3�-s <br /> 0 <br /> PA to I 3 c...1-114,4.../1-c- p09- 0 /S.&00 <br /> Property Owner's Mailing Address Property Location <br /> h 6 74 in ; dAre P/4.ce S"g'S f Govt.Lot 3 <br /> City,State Zip Code Phone Number / %, Section 33 <br /> /rio/0/e. In,0 0.R .173—/f 1' (circle one) <br /> T 4// N; R /b E ort <br /> II.Type of Building(check all that apply) G t r,,,,,s G a.,'.J. Lot# <br /> 0 l ort Family Dwelling-Number of Bedrooms Tai(e Subdivision Name <br /> Block# <br /> • <br /> ❑Public/Conunercial-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use <br /> ili Town of 5w r Ai. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' ❑ New System y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> /q ot,' Serii4 p i.vvvp f4'''' K <br /> B. ❑ Permit Renewal ❑Permit Revision <br /> ❑Change of Plumber ❑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 /> g Non Pressurized In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Bolding Tank 0 Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 4470 S e a fa.cLtei 4 )4 ) <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units `o ''" U <br /> New Tanks Existing Tanks o v ° 2 <br /> C",U y C7 a. <br /> Septic or Holding Tank rile, / \ / <br /> Dosing Chamber.. 1,O S�1O hrt (�P� o r ) X <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 MP/MPRS Number Business Phone Number <br /> p j / t-d--.1 d f/ 7/s= f'66-'''c7 <br /> Rt CA `Gtr <br /> � <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 77 G o 74u-1 3-r l/ve 4-5 7(1/ ti- r .S el SYSY <br /> VIII.County/Department Use Only / <br /> �pproved ❑ Disapproved Permit Fez Date sued ssuing A ent Signa e <br /> ❑ Owner Given Reason for Denial <br /> $ j, oo f 21 202o <br /> IX.Conditions of Approval/Reasons for Disapproval -�� f R�/ -� <br /> -ii i $K( be wed, ^ ii v <br /> !d 0.0 SckS ewt f o 'M dt. 4 r b&tWOOIM ` <br /> •.--'t P. .1It ow. . ,/ ' > ovht. all latAks , J U L 2 7 2020 J <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a ll inches in size <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R0313) ?Ii J /.,ceril?/ <br />