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,.-;;;,-,_,,,:%„!;-N, Industry Services Division County <br /> 1400 E Washington Ave Liti riVeit- <br /> /;.:: <br /> Pi :\$ - P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> '$ Madison,WI 53707-7162 t}--20— 1�3 <br /> c:;_ ‘ '� C51-- .9.1) - 15y <br /> Sanitary Permit Application State Transaction'ANumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit ��O 3�p <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. `/ <br /> I. Application Information-Please Print All Information 5t,0 N G k a <br /> Property Owner's Name Parcel# <br /> /am Te—//e4 o Z-2 q/-,6-l3-(06=e277-061200 <br /> Property Owner's Mailing Address Property Location 11 <br /> /�134 <br /> ygbg Wade/Vied Govt.Lot 41 <br /> City,State Zip Code Phone Number 1 3 <br /> 1, /., /�, Section <br /> whl L re� 1 k- A 5570 6'/•74/7 yZ�j (circle one <br /> II.Type of Building(check all that apply) J Lot 4 T �� N; R / E ot�' <br /> Y• I or 2 Family Dwelling-Number of Bedrooms 2,-- �aV�� Z Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> CrTownof 4Wr47, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System 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 Plumber 0 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 /> iF}Non-Pressurized In-Ground ❑Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 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(sf) System Elevation <br /> 300 . 1 yzy y3',a pop95:I1935 <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons Gallons Units v o b <br /> New Tanks Existing Tanks v c v +n . <br /> b <br /> aV in H i.: 6 .. <br /> Septic or Holding Tank /6 IU • — /o yo . IN �N,,` 1_. <br /> Dosing Chamber v j jL7` <br /> VII.Responsibility Statement-I,the undersigned,assume respon 'bility for installation of the POWTS shown on the attached plans. <br /> Pe <br /> r's Name(Print) Plumber's Sign re MP/MPRS Number Business Phone Number <br /> Amt /l/Qay ...42.---,285/957/ 76--sg-azo-Z <br /> Plumber's AddressStreet,City,State,Zip Code) <br /> ( <br /> beet A,( /,-,./ L l' ii k1e16 /er- tit' 5'69 3 <br /> VICounty/Department Use Only <br /> Approved 0 Disapproved Permit Fee DDaate sue gent`ignature <br /> 0 Owner Given Reason for Denial <br /> tJT�• `y ���'D�� <br /> IX.Conditions of Approval/Reasons for Disapea eUbf .1 comma g• rVJ/1,1 t/wiii• <br /> •atmek, gwtp fel* 04, <br /> • * Ct d woof be pawkitel fe slope. <br /> • 3.&t wu be k 4C04. odl {its f 1561'tBreda d. TE © i II V I Th <br /> Attach to complete plans for the system and submit to the Countyonly on paper not less than 8 trt x 11 <br /> size <br /> 3Alk 1 2020 <br /> SBD-6398 R.08/14) <br /> Burnett County <br /> LLand Services Department <br /> via. hi.*IA e./w/Allis <br />