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----------- <br /> -7.,...:„.i..--; County�, af-t/ , <br /> ;.. "'";:"1-\ Industry Services Division cn✓'heti--- <br /> ,zi i::t'r:::: .,-P• 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> eA, ,1.., .$ j Jf P.O. Box 7162 SP-J-.2-6-.2 74 <br /> ''S• Madison, WI 53707-7162 <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 L )10 1 <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 Servies. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. `CA 0014 QV V' /�j(` <br /> I. Application Information-Please Print All Information J a/�- ) 353.(s <br /> Property Owner's Name / Parcel# "YD 44 .-,r; --3--o-17.OD7 <br /> J p 111A A./ tiv' o 7-aA0_d 0/'D OO <br /> Property Owner's Mailing Address PropertyLocation <br /> 4 '788 Ra veil Ct Govt.Lot 7 <br /> City,State Zip Code Phone Number <br /> w, y,, Section 0t j <br /> "04 Prow;e_ m/V T `y0 N; R l o <br /> (circle one) <br /> re <br /> II.Type of Building(check all that apply) Lot# <br /> ® I or 2 Family Dwelling-Number of Bedrooms 3 el Subdivision Name , <br /> Block 4 <br /> ❑Public/Cormnercial-Describe Use ❑ City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use <br /> V- /3 /2 7 a`7 A Town of Ost ///4nd <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 4 New System y 0 Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Chane of Plumber ❑Pennit Transfer to New <br /> List Previous Pennit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS.System/Component/Device: (Check all that apply) <br /> ikt'Nian P,essurized In-Ground ❑ Pressurized In-Ground 0 At Grade 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> , <br /> ❑ Ffolding Tank ❑Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.,Dtspers`al/Treatment Area Information: <br /> Design'Fld*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 4/3--0 , `y //okS //oCS 93.-5- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> 13 <br /> Gallons Gallons Units o- 0 <br /> New Tanks Existing Tanks 9 c •n E <br /> 0 <br /> a U rn u cr u.o a <br /> Septic or Holding Tank <br /> /0 60 /DGO / .274/lAk-a►/,, X <br /> Dosing Chamber_ I .)1 <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number • <br /> /?/G/4 l% /e/4 1 / o4015-8:5-/ 7/. <br /> -/ S= y'a,6-e/ r7 <br /> Plumber's Address(Street, ity,State,Zip Code) <br /> 776 0 /,lt..- .3S" Gv Qbsfr. lN1 S-`/a' 3 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Pennit Fee Date Issued Issuing Agent Signature <br /> $ 37S q 4- /,/'LI/ <br /> 0 Owner Given Reason for Denial /Z. /' ZD <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> irli [EICEOVIEN <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x itrJhes-ar size <br /> Burnett County <br /> SBD-6398(R0313) Land Services Department <br />