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N <br /> .., .17if.= County <br /> 45'' `?1;\ Industry Services Division i5Gt v'n t <br /> ;te (I s •i' 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ins`-�' ;, P.O. Box 7162 C/1,.f r,�„g0 <br /> v;5`..\, 4; ,..- 4, Madison, WI 53707-7162 v11 <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 64344/ _ <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 s g8 6 y��. <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. / <br /> 4 <br /> I. Application Information-Please Print All Information •Sw eq er re, <br /> • <br /> Property Owner's Name Parcel# <br /> 0 <br /> 544146 7-oIA-e1-yo; ;7000 O5- 0 o <br /> Cpr y 4r-it <br /> Property Owner's Mailing Address Property Location <br /> /3 yC 3 C•o& in roed tv4 y Govt.Lot <br /> City,State Zip Code Phone Number / y,, Section 7 <br /> tvfe/11 punt rh N 5-56 6* 0 (circle one <br /> II..Type of Building(check all that apply) Lot# T y N; R LS E or ! <br /> id 1 or2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> 0 Town of JO-4445441 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System 0 Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal CI Permit Revision ❑Change of Plumber <br /> CI 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 /> N N"on Pressurized In-Ground ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑-Halding,Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.lJispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> La-t) ,S ✓ 90o qoo 93. 5 / <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units ` o 0 O <br /> 41 <br /> New Tanks Existing Tanks ,U o a ' 76 `ca m <br /> nCZ . cn w U a, <br /> Septic or Holding Tank ODD jdDD I sJGAW <br /> Dosing Chamber.. 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 Signature MP/MPRs Number Business Phone Number <br /> 2 € f No.k►frps /2 ....e - ' , As-v- 7�s 04 -4/477 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> )77O /4 3_s" l/I/c,6.5 fe v WI- .SZ/891 <br /> V.IIICounty/Department Use Only / / <br /> CTproved ❑ Disapproved Perrniit Fee Dat- [ssu i ssum_ cent Signature <br /> ❑ Owner Given Reason for Denial $ �" 5 if , - / <br /> V 1 <br /> IX.Conditions of Approval/Reaso s for isapproval i hj <br /> 44 wucat bc. sa f f✓oeu C C M C <br /> W c WI Isaac .2 Obte rvakovt pipes. 1 I <br /> A1. ..r -4e bG P. Ai •44% I t/, ' I u I ' <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/2 a 11 in•r•int e <br /> r ; Burnett County <br /> SBD-6393(80313) <br /> Land Services Department <br />