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l <br /> I <br /> e,,r0-.2211.. Industry Services Divis'ion County <br /> --,,,..„ 1409 E Washington Ave D ixiiie-rr <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Ca) <br /> 41 •,,,Sp ' <br /> Madison,WI 53707-7162 <br /> State Transaction Number <br /> Sanitary Permit Application <br /> In accord:nice with SPS 38321(2),Wis.Mm.Code,submission of this fonts to the appropriate governmental unit AA <br /> I is requited prior to obtaining a sanitary permit Note:Application forms for state-owned POW1S are submitted to Project Address(if different than mailing addicts) <br /> the Department of Safiny and Professional Sesvices.Personal information you provide may be used for secondary <br /> PutPoses in accordance with the Privacy Law,s 15.04(1XmOtats <br /> L Andantinos Information-Phase Print Alilehmrmaii5)_.;qt) PtA.r: EN,0 R014k° <br /> Property Owner's Name , Parcel# -4t- <br /> ,--. <br /> YAM A. DiAFkc... k,te, (,)-7-0:7.) ,..,-.2.-21c1.j 7-3(,•-3.- /5--5-it--, <br /> P.upeai Owner's Mailing Addicts Property Location C;i 7041 5-i <br /> (517 37 0 V.11--3 FUCK biZtliE <br /> Govt.Lot - Ott 1 Ot <br /> - <br /> City,State <br /> Li N.t: LA KES ,Alki\i <br /> ,11.Type of Building(cheek all that apply) <br /> LI Zip Cede <br /> Fatuity Dwelling-Number of Bedrooms <br /> 61 <br /> 55.63 S Phone Number <br /> Lot N <br /> 41.141.- <br /> (at...vuocti - 3 1 .)-e‘L—k.6*0111 St.P-siA^-c6 1 1 — vs, — v., scction 34, <br /> (cone*, <br /> T 1-jt N; It 1 7 ircle E or j <br /> Subdivision Name <br /> 1 or 2 Fa <br /> D Public/Commercial-Describe Use I 0 City of <br /> CSM Number Oyillage of <br /> 0 Sum;Owned-Describe Use <br /> ----- ..)2(Town of irtN.)I N <br /> III.Type of Per (Cheek only one box on line A. Complete line B if appfitable) <br /> IL 0 New System Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision E3 Change of numbc, a Permit Tionsfet to New List Previous Permit Number anti Date Issued <br /> Before Expiration Owner A;K <br /> IV.Type of POWTS Systme/Componest/Deviee: (Cheek all that ripely) <br /> )E4 Non-Presstaized M-Ground E3 Pressurized In-Ground 0 At-Grade C)Mound>24 in.of suitable mil Cl Mound<24 in_of suitable soil <br /> 0 Holding Tank AOrher Dispersal Component(explain) 0 i---7E1C. XPretwahrient Device(explain) 4--,Er /1/ti)t-7- <br /> , <br /> V.Diapersalifreatment Area Information: , <br /> Design Flaw(gpri) Design Soil Application Ran(midst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Blevatinn <br /> 6700 /4 c 2.C.' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units .. <br /> New Tanks Eszion Tanks ap f sl ] 13 ] <br /> li.0 'if)U Cil it 5 m <br /> Septic ar-HeittairTnak 4 000 ? 112c 0 1 pO/E3Eg. X ' <br /> Dosing Chamber e,50 [75 ) 1 <br /> i .. <br /> VII ItelpounilbsTsty Statement-74 the understved,sae -,:ii.•T.•f. Sae instsilotion of the POWTS shown ea the attached plasm <br /> Plumber's Name(Print) MRAMPIR&Number I Business Picone Number <br /> ‘40/4 1:,ZiegsioAl 4 5 24 339* 171 5--&64-52`15‘471 <br /> . <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 930 b 041.46K BRoOK Rd:>-,) w93s-7--Er? (4)-1- - <br /> VIM Countypepartment Use Only <br /> )('Approved 0 Disappmved Permit Fee Date Issued Issuing Agent Signature <br /> 0 Owner Given Reason for Denial '---'i''''• ---, A -2.Z•z <br /> CC Conditions of App Reasons for Disapproval <br /> — <br /> Mink to complete plow.itt.do system and submit to the Coolly et*go piper ost less*as 8 sex 1 elk.4 Li 1 <br /> q ECEOVE1 <br /> - SBD-6398(R.08/14) <br /> H OCT 1 6 2020 _J <br /> — <br /> Burnett County <br /> Land Services Department <br />