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.60..0- 141` <br /> County <br /> Or� , 1)+p <br /> + Safety and Buildings Division W <br /> ® ` 0s 201 W.Washington Ave., P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> a p$ SCA Madison,WI 53707-7162 nA I — tit <br /> _.0' CS► -.2T -l6 <br /> � <br /> State Transaction <br /> 7Number �o2232 <br /> Sanitary Permit Application <br /> PV1/44,56)5Z006 accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit " 1, 655CO °t ` C. <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. - <br /> I. Application Information-Please Print All Information L <br /> Property Owner's Name Parcel#67-ow ",t./0 I t (25Z-55 <br /> 5Z- <br /> PO RTS CA NSP PROP6R`rls 05 Z o i/500 <br /> Property Owner's Mailing Address, n Property Location? `++✓✓��®®078— <br /> 3t1Z `k) 1NL1313 LAKE QR Govt.Lot i42, <br /> City,State Zip Code Phone Number y, y,, Section , <br /> D'AII$W21 YV l S y8 63 /6 <br /> circle one <br /> II.Type of Building(check all that apply) Lot# <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> glkiblic/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of �L, 11 <br /> gTown of �10 . <br /> III.TN*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 Modification to Existing System(explain) <br /> ❑Change of PlumberList Previous Permit Number and Date Issued <br /> B. 0 Permit Renewal 0 Permit Revision g 0 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade tir 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 /> 675 I 675 6 75 `l i • <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o o <br /> u <br /> wFu <br /> New Tanks Existing Tanks � V .v A R <br /> n O in <br /> Cl) t:. 0 ta. <br /> Septic or Holding Tank 15}8 5 /5©5 /I 16 V <br /> Dosing Chamber s�o R� C <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for i tallation of the POWTS shown on the attached plans. <br /> Plum er's Name(Print) P igna M1 RS Plumber Business Phone Number <br /> EPP- I/ Z2-3Z9Z 71 5"-119 r 395e. <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Pon,_ S pRe R iv! SyOOcr <br /> VIII.County/Department Use Only <br /> pproved 0 Disapproved Permit Fee DateI,su gentgna e <br /> $ 203 b <br /> 0 Owner Given Reason for Denial i / <br /> - <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> X E(fl+mwf gtftlr gefuirtie. D b E C E O V E �11 <br /> it al Welts lM,ksf lotaft, A *d pv.i ct 40440 te H ses '• 1 <br /> ""Co*** !i Co. Wkeu w�awu 4 is le be pl• 4. Y AUG 0 7 2020 jj <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 I c in size .../ <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) bL L 101Zk 1,37(" 6 <br />