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;� �* D Industry Services Division County <br /> /,-,i, 1400 E Washington Ave Vrl�! <br /> I;I ti. $p 't P.O.Box 7162 • Sanitary Permit Number(to be filled in by Co.) <br /> $ Madison,WI 53707-7162 cJflNi_��_2F <br /> ",.. <br /> =_,-,, _,: e51-,: -65 01-(3�8 t <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),\Vis.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(I)(m),Stats. . <br /> I. Application Information—Please Print All Information 28�y� J e',ye 404 G+- <br /> Property Owner's Name <br /> _ Parcel# <br /> /a�'/b/ g Ai p7,o/1-1-k0-�5:13-5-/5-''�S'-o33trxx) <br /> Property Owner's Mailing Add ess Property Location <br /> 24/d4 j2I m/iVe /VW Govt.Lot <br /> City,State Zip Code Phone Number , <br /> N IY:4 /iiti 0700 /+ 'A,, Section 5(� <br /> cle on <br /> H.Type of Bui ding(check all that apply) Lot# T 7U N; R E of <br /> II or 2 Family Dwelling—Number of Bedrooms Z 2 J Subdivision Name <br /> Block m <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CS1 1 Number 0 Village of <br /> 5Town of T4ck <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 1.--/ <br /> LY New System 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 Chan a of PlumberList Previous Permit Number and Date Issued <br /> g 0 Permit Transfer to New <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.DispersallTreatment Area Information: <br /> Design Flow Design SoilApplication Rate(gpdsl) Dispers�Aea Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3 /7�3Z %?Ze 99/.# <br /> VI.Tank Info Capacity in Total Y of Manufacturer <br /> Gallons Gallons Units = <br /> a O <br /> New Tanks Existing Tanks �r U <br /> J V N <br /> Septic or Holding Tank /DA/1 / / 1/0le i /tV t <br /> Dosing Chamber vVvv <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plun er's Name(Print) i Plumbc' ignature MP/MPRS Number Business Phone Number <br /> /ol1Q � %�I 86'l 9'5zr 7IT-'5 -6202 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6t8( %t' ri L1c i f kJei VI' 54/4593 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Feet r70 Date Issued Is. 'n Age, Sigma <br /> 0 Owner Given Reason for Denial If a 5 —^ 5/ q?'d � �"'�lA <br /> IX.Conditions of Approvval/Reasonssffprr Disapproval <br /> eek. 4 f� 546t <br /> to complete plans for the system and submit to the County only on paper not less than 8 iP s t1rE [IVE --- <br /> Attach 1 2 2022 d <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08114) ? 'I, ly `-1 i 7 p5 <br />