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:t``=",,, Industry Services Division County <br /> /VeL <br /> 1400 E Washington Ave t— <br /> `j 0s P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> $ Madison,WI 53707-7162 SN i—JD —.25C� <br /> ✓n`r <br /> ;zY``- 7,w" �3/�/� <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 governmental unit �— <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. 15.04(1)(m),Stats. p <br /> I. Application Information—Please Print All Information 7092 /.k 1/ 0/' <br /> Property Owner's Name / Parcel# -ZZ.D.3I <br /> (40NA eroAW.I/44 ie- 07-02-2494-27-1 -aod v/3ao <br /> Property Owner's Mailing Address Property <br /> p�, Property Location <br /> /071 will Govt.Lot <br /> City,State Zip Code Phone Number X= /.{ !J(/4. th, Section 2 7 <br /> . , I circle ons <br /> ,1_,/r//V `� "� T "I 1 N; R �6 Eo� <br /> II.Type of Building(check all that apply) ' Lot# <br /> 1-4 I or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> V, P.7/Gy Town offw s`S'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 0 Change of PlumberList Previous Permit Number and Date Issued <br /> 0Permit 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 0 At-Grade 0 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(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> KO — <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units ° o v <br /> New Tanks Existing Tanks E 2 u , m ca <br /> a U i7 y cn ir. C7 a <br /> Septic or Holding Tank /22 4 L`7 Zea', . �w y <br /> Dosing Chamber ✓7 vCJ `^'V <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) Plumber's S' re MP/MPRS Number Business Phone Number <br /> AO, 1/kAdV - ���2'� 85795'/ 7/5--1-g-02oZ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6 S8AM- <br /> / a Ile /2/ k1e6 / (.1.‘ 51/69 3 <br /> VIII.County/Department Use Only <br /> pproved 0 Disapproved Permit Fee Date Issued Lssuingent Siggature <br /> 0 Owner Given Reason for Denial $ 3 7S:--- i l- �//�,�� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> X35- <br /> �� 1 t����----M— 1r�� <br /> tii a• /-cam of GI / i^ c O/pit e_d-- V l <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 in,� 4ze NOVV - b 2020 333 <br /> _ 5 <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br />