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-=:"% Industry Services Division County �,�+ <br /> iii 1400 E Washington Ave ffuriv <br /> ® P.O.Box 7162 <br /> 1;l ,.\Sp Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI 53707-7162 -ao-.Z7• <br /> 63 / 'ta3 <br /> StattTran on 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 <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. <br /> I. Application Information—Please Print All Information Z79 /i/yf <br /> a/ <br /> Property Owner's Name Parcel# <br /> & ,.d, Sei/e't- 3 . <br /> ` OPr� 9l •zer-i 0Z'kb-olt/00 <br /> Property Owner's Mailing Address <br /> 61�AV■74Nhk/�/ Govt.Lot <br /> City,State Zip Code Phone Number N� y , 2 <br /> tAte/ i� /y, /� Section <br /> 6 //,� cle one <br /> t T 7 0 N; R f E o� <br /> H.Type of Building(check all that apply) w Lot# <br /> ry I or 2 Family Dwelling—Number of Bedrooms G Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> 4# ry ��y �To,vn of � <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> 0 New System itReplacement 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 /> (Cron-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 A4ication Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 3DU 2(J .#ft) q?-" <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v o 'b <br /> New Tanks Existing Tanks w F, y a b A <br /> e- v in a' rn i O e, <br /> Septic or Holding Tank TJ II w.71,0 _, we p <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume res.t nsibility for installation of the POWTS shown on the attached plans. <br /> PluA cr's Name(Print) / Plumber's Si_ MP/MPRS Number Business Phone Number <br /> (Of* T d 9Adt/ / 86/95-775-.5-g-4524-z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> c <br /> c 5f ,4, w lie 4/ (Ve6 LA` 5y69 3 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved 7 <br /> Permit� Fee Date Issued Issuing Agentka <br /> Signature <br /> 0 Owner Given Reason for Denial $ J 7 - A* '2i. 4)/4(lo'f.�'�1✓{VJ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> I--� E C E l V E Th <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 ncTics n size <br /> OCT 2 6 2020 <br /> BURNETT COUNTY <br /> SBD-6398(R.08/14) ZONING <br />