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4,7 k?: Industry Services Division County <br /> ;x;, 0 ;i`, 1400 E Washington Ave U f�(�� <br /> 1;1 Sp •' ;= P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> S Madison,WI 53707-7162 S W_ 2-85 <br /> State Transaction 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 addr s) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary i1"Y TO <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Slats. a <br /> I. Application Information-Please Print All Information 4' Z ' /jlt6/I f fee 7t// /Le. <br /> Property Owner's Name Parcel# <br /> Eli G Apt^/ 07-0l4-40-rf-/o-f-if-Z9o-o9Atrj <br /> Property Owner's Mailing Address Property Location <br /> 9/Z 5 idnl do&eV/4 - Govt.Lot <br /> City,State ' I Zip Code Phone Number '/4. V,, Section /0 <br /> W"aTGerr Lk WA) $jIIU '// cle Type of BuildingT lib N; R /�j E on <br /> H. a <br /> (check all that apply) Lot T <br /> I or 2 Family Dwelling-Number of Bedrooms Z' Subdivision( Name /J <br /> Block m /70/�/'A/ MY le <br /> ❑Public/Commercial-Describe Use T <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> 5rTown of glekSoA( <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> TiNew System 0 Replacement System ❑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 Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 306 . 7 y2 9 y3Z 9/5- <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units c"z <br /> U =New Tanks Existing Tam E o = E u .c e, ca <br /> U n v: cn ir. t7 a <br /> Septic or Holding Tank goo noo I 5k�r ! y i <br /> Dosing Chamber goo i! W <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plun er's Name(Print) Plumber's • aturc MP/MPRS Number Business Phone Number <br /> Oe* T��� /ate 87al 9V. 7/5--� -azd-z <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6 8/ l / ev i k ,f (Aie6 LA- 5 59, <br /> VIII.County/Department Use Only <br /> 'Approved ❑ Disapproved P it Fees Date Issued Wit`t Sign e <br /> 0 Owner Given Reason for Denial <br /> 1?-5 5117/�� <br /> IX.Conditions oft....._pproval/Reasons for Disapproval <br /> die411 5 e.ciCs <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1P_i 11 i <br /> _ <br /> l size <br /> MAY 1 2 2022 <br /> SBD-6398(R.08/14) Burnett County <br /> Land Services Department <br />