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4--- Industry Services Division County <br /> 1400 E Washington Ave / i,')e <br /> ;s , S P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> g Madison,WI 53707-7162 S'AN -25 9- <br /> �i 43 1 "/l I <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. <br /> L Application Information-Please Print All Information <br /> Property� Owner's Name Parcel# 3 SZ 5-1"5-1"/\op11r rl t 'S tr., /8.._z/-5 "-GS-ci - 3V17 <br /> Property Owner's Mailing� Address f Property Location <br /> / ZcS t i,�'1�k 7 rade_ QC. Govt.Lot I <br /> City,State Zip Code Phone Number ih, /, Section i <br /> gr en-yl iS yr 4-4) c ,S�g.t (circle one <br /> T 8-, N; R 152Eor <br /> II.Type of Buildingreheck all that apply) Lot# <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms / 1 X161 fcx / <br /> Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 36'Vg<:o>t ( Yl'' Town of /7-4-e(et Lrtk>,`. <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Fr New System 0 Replacement System ep ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> I- List Previous Permit Number and Date Issued —11 <br /> B. 0 Permit Renewal 0 Pennit Revision 0 Change of Plumber 0 Permit Transfer to New <br /> Before Expiration Owner <br /> N.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 ❑Mound<24 in.of suitable soil <br /> ®-Holding Tank 0 Other Dispersal Component(explain) ❑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 /> VI.Tank Info Capacity in . Total #of Manufacturer <br /> Gallons ,Gallons Units :? V <br /> New Tanks ExistingTanks <br /> ' • a U iii i, rn ti. Ci o. <br /> Septic or Holding Tank <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assaune responsibility for installation of the POWTS shown on the attached plans. <br /> Pt 's Name(Print Plum s Si7reaL MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> � .l2. /15 ./41. s i , -rF j_Er-.`e- c..e.i e -C6>-i'' 91 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuing Agent rgnature <br /> '' `` <br /> 0 Owner Given Reason for Denial a���I J/-5--20 Lt/. i <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 'F----1-61—liTifk <br /> �� Iü . <br /> /f 7— GS/`ec.AAeiifi 1'eebtannmGL <br /> Attach to complete pians for 14 systems and shit to the County only on paper not less than 812 'Ill 9i•Nev 2 2020 <br /> jii 6..:F <br /> +9 ._.__1 <br /> Burnett County <br /> SBD-6398(R.08/14) Land Services Department <br /> I 0 4oq i <br />