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N <br /> v�r`i'' r-,y County <br /> 7 '^; ' ,';\ Industry Services Division <br /> ,.e/ a:f ,. ;,. . 1400 E Washington Ave Sanity Permit Number t <br /> r. ,;,,,4;;j;,;, ) ry (obe tilled inbyCo) <br /> .. r P.O. Box7162 G+nW— 3--Ltff <br /> 4ss Madison, WI 53 70 7-71 62 t,d5b95 i <br /> '-t ,-,Y-,. i C51— — L11- <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 Servies. Personal information you provide may be used for secondary ii SOS <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. S fa t� ?4� Q I. Application Information—Please Print All Information O <br /> Property Owner's Name Parcel k 3 7—/8—a 7_5 ' -s— <br /> /Obe✓r �eei- Orb `�_�, <br /> PA <br /> ooH D/ravC7 <br /> Property Owner's Mailing Address Property Location <br /> / (P 2 I ?e&t 13a y Govt.Lot (t <br /> City,State Zip Code Phone Number 14 y, Section of 7 <br /> wa6ai LiAvy 44 N ,-S/As' (circle one) <br /> IL Type of Building(check all that apply) Lot# T 3 N; R /� E o� <br /> VI or2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> • <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned—Describe Use �p- <br /> CSM Number 0 Village of <br /> Town of /Ybe% L/< <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System DrReplacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Permit Revision List Previous Permit Number and Date Issued <br /> ❑Change of Plumber ❑Permit Transfer to New <br /> Before Expiration Owner - <br /> IV..Type of POWTS.System/Component/Device: (Check all that apply) <br /> ❑Non suri <br /> preszed In-Ground 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil .el Mound<24 in.of suitable soil <br /> ❑ Efoldm=Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V..Dispersal/Treatment Area Information: <br /> DesigifFldW(gpd) Design Soil Application RR te(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 4/5-0 _ /• 0,19 199 /00, /S- <br /> VI.Tank Info Capacity in Total #of Manufacturer 9 <br /> Gallons Gallons Units -, o'o <br /> New Tanks Existing Tanks o u ro <br /> c,U cnn . db w t. G. <br /> Septic or Holding Tank /e .e /0 B o l <br /> Dosing Chamber_ !G 00 6Oa / /- I ').t <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 Sigma re MP/MPRS Number Business Phone Number <br /> R/G�G %/ /7 s / 01)5"--0 � -74s 8-a, -Q/57 <br /> Plumber's Address(SCreet,City,State,Zip Code) <br /> VITI.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee 00 Date Issued Issuing A ent S°na, e _. <br /> 0 Owner Given Reason for Denial S 375 51�l/o `Q �j ' - <br /> IX.Conditions of Approva/Re sons for Disapproval ILECE {IVE 1-1 <br /> filet-C. a k 55 -I. 54/e :renioi <br /> 11 MAY 1 0 2023 j_jz__ <br /> Attach to complete plans for the system and submit to the County only an paper not less than 8 1/2 a 11 inc hes in s <br /> Burnett County <br /> Land Services�j DDepartment <br /> nn'' <br /> SBD-6398(R0313) Mt 73(�7 3 3, <br />