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c;::: '>> Industry Services Division County <br /> \;`, k/ <br /> 1400 E Washington Ave u(nJ <br /> (r {' ®S - P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> $ Madison,WI 53707-7162 84N -az-Irk <br /> <' <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unit {lr�o/4/r <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. I5.04(1)(m),Stats. v7 �A �'��� <br /> I. Application Information-Please Print All Information iv4 <br /> Property Owner's Name Q� Parcel# 4?J'J-1t 2 <br /> led Fare. o7418-z-3?-,6-76-5-oS-c03-olberb <br /> Property Owner's Mailing Address Property Location i , iigQ <br /> /7P ,i-c,/e,'.ar Govt.Lot 3 it ttiit <br /> City,State Zip Code Phone Number /,, /,, Section 0/ <br /> p <br /> QQ N I;--NW -trzT q crrcle one <br /> II.Type of Building(check all that apply) '/Z, Lot# /' <br /> ( .I or 2 Family Dwelling-Number of Bedrooms y Subdivision Name <br /> Block# / <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number�J 0 Village of <br /> V6 P3r✓ / 5/Town of Mecei 'o J <br /> III.Type 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 /> B. 0 Permit Renewal 0 Permit Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> ❑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 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> pHolding Tank ❑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 /> 4'50 ✓— <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 9 o b„ <br /> New Tanks Existing Tanks d o v u b <br /> a. Q in y cn iz. U a <br /> Septic or Holding Tank ZctYa 2a L,k, Y <br /> Dosing Chamber C/ J <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu er's Name(Print) / Plumber's . rc MP/MPRS Number Business Phone Number <br /> /0* T l/QAdc/ /C� �, 86/951-/ 7/5--.5-g-620Z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 688/ ,v�M w Ile / / ti/e6 /..er- L/1 5'169'3 <br /> VIII.County/Department Use Only <br /> Approved CI Disapproved Permit Fee Date su d gent Sign re <br /> 0 Owner Given Reason for Denial $3 • 94'2030 <br /> IX.Conditions of Approval/Reasons for Disapproval �"�"�'��� <br /> ifOv41� if jstr ru t mute he ed I seeded. <br /> ,40 44, >23 p 444 ail wells. n rg, c rE \\_ii E : . <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t2 x 11' \{Lykslae <br /> 11 AUG 312020 u <br /> i...../ <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br /> A✓.a.,/J g1- 00 <br />