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00 <br /> /_,i;'r '"aA y0 Count <br /> r r '`„4 Industry Services Division (11^rn� <br /> � + El 1400 E Washington Ave <br /> r 9 Sanitary Permit Number(to be tilled in by Co.) <br /> ` P S;, 1 P.O. Box 7162 SAN_2D-(03 <br /> rti t <br /> ',:: ,r„ . P�ladison, WI 53707-7162 <br /> '>,.;,� 1 e.37-,,2o"53 <br /> Sanitary Permit Application <br /> StateTransac/tio_nNuzmber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit (y/'"'1"?.° <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different thin m dress) <br /> 01 7 <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary it #.i3 '' ' <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. J <br /> I. Application Information-Please Print All Information w Connmr'S 14/4. /740/ <br /> Property Owner's Name Parcel#97-p of O-4.iio-/6 '3s-5-- <br /> M 4//4 ry <br /> S'mal/ery Pe?t'tC 'i , 0o) " 611Aec <br /> Property Owner's Mailing Address Property Location <br /> )t ?4743, iv, �snne.j GA /?/<• Govt.Lot 3 <br /> City,State Zip Code Phone Number y, V4, Section 7s <br /> f e f ty (�� diel circle one) <br /> T y0 N; R ap E o� <br /> IL Type of Building(check all that apply) Lot# <br /> KI or 2 Family Dwelling-Number of Bedrooms 3 ) Subdivision Name <br /> Block# V• #14, A 3 <br /> ❑Public/Cotrunercial-Describe Use ❑ City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use r <br /> jg Town of &k-t'a .d. <br /> IIT.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B• CIPermit 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 /> 0-Nor Pr•essurized In-Ground ❑ Pressurized In-Ground ❑ At Grade 2 Mound>24 in.of suitable soil CI Mound<24 in.of suitable soil <br /> ❑ Floldut>Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V..Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) T Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> gra ,85 I 41.5-0 cSo 4/ + "7. o "/ <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units oQ <br /> U y <br /> New Tanks Existing Tanks i o - <br /> y "c <br /> a U 65 H inn w C7 a, <br /> Septic or Holding Tank /Cad /00 0 ,/ <br /> Dosing Chamber.. a� • /Bv / ��� *� ,J�` ) ) <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 SignatureSiMP/MPRs Number Business Phone Number <br /> / I C/G 404,H s /�c h...f /� ,�.: of,As-es-7 7'- -9447 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> of 776 0 ././..-7 ,7',m webs ,- .w„.. . - 58 ?3 <br /> VIII.County/Department Use Only / / <br /> /� Approved ❑ Disapproved Permit Fee Date las ed sluing gent Signa e <br /> $ <br /> VV <br /> 0 Owner Given Reason for Denial r I•� 5VDate <br /> Ib '�/ <br /> IX.Conditions of Approval/Reasons for Disapproval legL ( <br /> M 6160 ail fiats reiw re is 1 iSte� elf/, <br /> * welt ,,,,,,,o be *Ft- { 0.4 +et off' mi D E 0 d <br /> it XVISt 11Ac'iov. Wtm.St be cbtihe iH. pryer ca iti•KS, <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 a 11 i tiles ize <br /> 6 2020 <br /> Burnett County <br /> SBD-6398(80313) Land Services Department <br />