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.7;:I 'v', County <br /> '.`%•;A Industry Services Division IN'H-e* <br /> ,?t tt� 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> `` 0 Hi P.O. Box 7162 <br /> ' s i i �.s Madison, WI 53707-7162 �AN�� 3 <br /> ',9D— iOa - <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adtn.Code,submission of this form to the appropriate governmental unit 62311( . <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 d 563s-- <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. <br /> I. Application Information-Please Print All Information r'i loc.-v.& CurProperty Owner's Name Parcel# d�1/_/('_3c-,S-p,5- OuI <br /> Pac 1/vIleev- ©7.634- - G l8/Do <br /> Property Owner's Mailing Address Property Location ii-SaMin <br /> I3,t 7 /yDA /4ve Nw Govt.Lot <br /> City,State <br /> Zip Code Phone Number / /4, Section 3 G <br /> A ri et over Iv 5-530 t4 (circle one) <br /> T 4/1 N; R /4 E or® <br /> IL Type of Building(check all that apply) Lot ft <br /> g I or2 Family Dwelling-.Number of Bedrooms y / Subdivision Name <br /> Block# <br /> • <br /> 0 Public/Commercial-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use <br /> .0 Town of .Sw i SS <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. . New System y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Iv[oditication to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber <br /> ❑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 /> EP Von PreS$t i-iied 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) 0 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 /> 60 o . 7 es 7 <5G9 • 9 S` <br /> VI.Tank Info Capacity in Total #of Manufacturer . <br /> y <br /> Gallons Gallons Units o "' Q <br /> N <br /> New Tanks Existing Tanks 61 §' u (E'2 6 ,E R w <br /> o - <br /> c,U cn y � c% V a. <br /> Septic or Holding Tank /.1.-5-6 Ids <br /> Dosing Chamber.. / t/�/ J < t-- + <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 /> n,-/e _ , , c ,4/ . dd,i-es T4s 9a- W5--7 <br /> Plumber's Address(Street,'ity,State,Zip Code) <br /> 6 / w, 33" W e L S71r✓ Irvs Sy s`i 3 <br /> VIII.County/Department se Only <br /> :Approved ❑ Disapproved <br /> Permit Fee Date[ssu pgent Sign e i / <br /> ❑ Owner Given Reason for Denial 3-• OS .. lb O)0 <br /> / <br /> IX.Conditions of Approval/Reasons for Disapproval 4. -3:3----4--4' 2 <br /> V rieACV Ckli must be Sof+ graoc we't. E © End 11 . <br /> w A pi M1 it t� �c uc* IPD <br /> w t 'vim 10 or ewer. 5 2020 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a I ch a si u J <br /> Burnett County <br /> SBD-6393(R0313) Land Services Department <br />