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.40,1111$*, County <br /> of A Safety and Buildings Division Rtr <br /> 1's ' 5$ v, N 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> b ,, U S Madison,WI 53707-7162 Llti 5 n,1 _ rio <br /> ,,t'.===';,'� f �� c5C-20 -15) <br /> ) <br /> Sanitary Permit Application State <br /> (TransacctiionnNumbberr T-1062B327' <br /> BAITS In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit -05 Z006 <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 /> .oses in accordance with the Privacy Law,s. 15.04 1)m),Stats. ✓ ���.35978 <br /> I. Application Information—Please Print All Information ; -Swig is <br /> Property Owner's Name Parcel# <br /> NOR-rCa 1P R ot- i 07--Ow 2 9(.-1‘-z -5 -OS•_ilea <br /> Property Owner's Mailing Address I <br /> ` t n Property Location oh 00/ <br /> :31 42. t WET31 LA1L.0 OR. Govt.Lot I'-.f Z <br /> City,State Zip Code Phone Number 1g /,, , Z <br /> , /,, Section <br /> 1 kr RJ J 1 5"4 gO3 rrcle one) <br /> c� T 110 N; R / tp E of <br /> II.Type of Building(check all that apply) Lot# <br /> 0 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> SPublic/Commercial—Describe Use <br /> ❑ City of <br /> ElState Owned—Describe Use CSM Number 0 Village of <br /> Jbwn of e)M4 u1V <br /> III.TN*of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. )Jew System 0 Replacement System yp y 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ElPermit Revision ❑Change of Plumber ❑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 /> Non-Pressurized 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) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: SI aJ(e K y Ciiikm k.'2.. <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal,Area Pr osed(af) Sy m E evation <br /> 6'7 5 7 %Li-3 )- %41.: 91 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> ii 2New Tanks Existing Tanks w = c, g o 0 r, <br /> kU in. ,in wt' Lr. <br /> Septic or Holding Tank toy 5 J6/5 1 1„ /ICS LK- >< <br /> Dosing Chamber 1 IN/ICS G Y� <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for in : tiOn <br /> of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) rgna•? // M'irfarumber Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P . e )( 56S L.K R. VW' 5`10i9 <br /> VIII.County/Department Use Only <br /> Permit Fee Date I su . ssuing •.entSignature <br /> Approved 0 Disapproved / <br /> ❑Owner Given Reason for Denial <br /> $345. °° 8/1 020 i s . //r/ <br /> IX.Conditions of Approval/Reasons for Disapproval r ' [ © [ I] v i <br /> 416416004 �1'e *MN vaust 4c a# 91. coat v <br /> idmuirt Ivo '� ticele t we kshd awed', <br /> 7b1., IIVJ(III. Lir)Rutrc.t. AUG 0 7 2020 <br /> Attach totomplete pladS for the system and submit to the County only on paper not less than 8 1/2 x 11 Inc,••in siae <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R. 11/11) 6 K#1029 <br /> �i <br />