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40::-.5,11..1--iN Industry Services Division County <br /> ,, � 1400 E Washington Ave /N � <br /> aS S. : P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> �. Madison,WI 53707-7162 — cU.— 1 g3 <br /> %,;u�. a. C -c2o- 11002 <br /> Number <br /> Sanitary Permit Application State Transaction'l�`'S34/ <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit {� <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. -7/ ,/�f2 / J <br /> I. Application Information-Please Print All Information 5g7‘ Ul''5 Lb tkiN 'S <br /> Property Owner's Name Parcel# <br /> UI'Cky 4Nek 07-070-Z-4/0-6-25'3'oh/-oro-o/, <br /> Property Owner's Mailing Address / ' � / Property Location <br /> re <br /> !yk ti./‘f "/J/ Govt.Lot <br /> City,State ,`�/ Zip Code Phone NumberZg <br /> �/ti!ihl r�(�//'/dN� (/1/t, 'J!-" l `7 �� b, �j� /y, i Sectionle <br /> (circle one) <br /> II.Type of Building(check all that apply) Lot# T �� N; R ��j E or W <br /> Sir 1 or 2 Family Dwelling-Number of BedroomsZ <br /> Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> 0 State Owned-Describe Use CSM Number 0 Village of <br /> Ia ) <br /> Town of ©af-{q'/ <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. try <br /> iv New System y ❑ Replacement 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 PlumberList Previous Permit Number and Date Issued <br /> 0Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> cif 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(sf) System Elevation <br /> W <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units u o v <br /> New Tanks Existing Tanks c v ` m tii <br /> a v 'vr h CI) 'u. 3 E. <br /> Septic or Holding Tank / O Z/yt .--i-.--i-- ` QV / Y. <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print)J Plumber's Sig.. ,/� MP/MPRS <br /> 857954/Number Business Phone Number <br /> t /p1�4 [4/ ��2� 7/S-sg-OZp-z <br /> Plumber's Address(Street,reCity,,State,Zip Code) / t I / / a <br /> 6667 /TvWr,,, L le /CG/ �Ve67 L✓t' 5 39 3 <br /> VIII.County/Department Use Only / <br /> Permit <br /> Fee Date sued suing Ag t Signature <br /> Agi;proved 0 Disapproved / <br /> �77 I. <br /> 0 Owner Given Reason for Denial $ a6 g25ft6 / <br /> IX.Conditions of Approval/Reasons for Disapproval .--,_.4 <br /> Al O&fia MUbt bo fia4114 of i saotid per 9383. 1 <br /> E © E riv Em\ <br /> tilelr af be 2$F Miot ark.. i <br /> AUG 2 is 2020 J <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1t2 1 A Mei, in size <br /> Burnett County <br /> Land Services Department y <br /> SBD-6398(R.08/14) eled 9066 4110. <br />