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-�� "R�"''�7 ' Industry Services Division Cmm <br /> .' 1400 E Washington Ave <br /> t=1.. S i'. P.O.Box 7162 �P <br /> � j'°, �Sari Permit Number(fo be filled in by Co.) <br /> \ ,'4 S ., Madison,WI 53707-7162 S _ j q.1 <br /> ti <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 6g8,34fJ <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Ad1ress(if d' tit mailin address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary ( '('.j I g <br /> purposes in accordance with the Privacy Law,s.15.04(1 xm),Stats. I / "I �s <br /> I. Application Information-Please Print All Information Wed 5 4-e r Gf// 4t1T3 <br /> P Owner's Name Parcel# <br /> �hf ) X014)90/P 07o?oz4-101223 . tri <br /> Property Owner's Mailing Address It <br /> i ,.56 I <br /> Property Location �j <br /> 'FL , "l S4ie:ibearli Pr <br /> City,jy,State <br /> r i^/ Zip C/ode(+� Phone Number -.7/7( (� ! v yS c W yti Section 2 <br /> "" T/ �i'fe1� ," 5 t"/ % 61?-3)6- / T ` 0 N. R �/f irclB or& <br /> II.Type of Building(check all that apply) Lot# v <br /> ),1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> '' \\ Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of mm <br /> iiil Town of V a rJcr 1,149 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. tEZ 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 Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <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 Sol Application Rate(gpdsf) Dispersal r u' (sf) Dispersal Area Proposed <br /> pens (sf) System Elevation <br /> SSG 0.? 643 4`44 '90' z 91' <br /> VI.Tank Info Capacity in otal #of Manufacturer <br /> Gallons Gallons Units °' O's U <br /> '6S <br /> New Tanks Existing Tanks `o 15 <br /> ° � 1fie .- i A p7 <br /> a <br /> Septic or Holding Tank /y/)/% I � <br /> COCl(S `"' Q t‘%L <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plurglaer's Name(Print) Plum s store P/MPRS Number Business Phone Number <br /> rei <br /> tl� ,sSctc� 1)O7e 7)S—szO? <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Y/7o0. ika ()My' 4f TreSr% � 1 C/ rPp <br /> VIII.County/Department Ul O ly <br /> Approved ❑Disapproved Permiit Fee Date u suing Age,t Signature <br /> iiiop.- 1 <br /> ❑Owner Given Reason for Denial !JI✓• �e 7 X20 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> it Well Kati, 450 0 ftp Dedwtiv► -doe. <br /> ECIEOVE <br /> 1.) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 U2 x 4is in size <br /> SEP 0 1 2020 j <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br /> id <br />