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'e...%:'' ', County <br /> 7 r , -1;.4 Industry Services Division 13t...,e n-e t <br /> ,:tf :V.tt::," A.. 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> to ', .xi P.O. Box 7162 5 _ _ 2.5 - <br /> Madison,u•/I 53707-7162 I(,e gig37 7 <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 /> ia 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 l g90 <br /> purposes in accordance with the Privacy Law,s.15.04(I)(m),Stats. O� <br /> I. Application Information-Please Print All Information Cvac. -t ry LIG Or;UC. <br /> Property Owner's Name Parcel# SOs-o Oa <br /> o7-014•)-yl,.1G-3Sv,17av0 <br /> Property Owner's Mailing Address Property Location <br /> 43-7)t /641, AVi Nw Govt.Lot <br /> City,State Zip Code Phone Number /, ''A, Section 3 S <br /> R o ,I a 7 e y Al N 5.-90 I y i trcle one „ <br /> II.Type of Building(check all that apply) Lot# T N; R �b E o <br /> w I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> • <br /> ❑Public/Cotnmercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> /g Town of ,st't/IjS <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System <br /> y ❑Replacement System ❑Treatment/Holding Tank Replacement Only jz Other Modification to Existing System(explain) <br /> A la( trans leer ranIG7.-D Sys' <br /> B. 0 Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑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 ❑ Pressurized In-Ground ❑ At Grade ❑ Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Floldsi Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V Dispersal/Treatment Area Information: <br /> DesigrFIci*(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 3 . 7 693 69f �'t3 e <br /> VI.Tank Info Capacity in Total #of Manufacturer v <br /> Gallons Gallons Units U 7 <br /> �+ N <br /> New Tanks Existing Tanks L o Y, <br /> c,o co ta Co u:u cm <br /> Septic or Holding Tank /000 MO S./eGt-✓ X <br /> Dosing Chamber- i :) <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 /> lee-/6, /47ito s /2w/L 79,07tA4 hires, 24r ce-4.- "57 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 177‘0 levy 35 fr.e6.5>lz• Nr 5-?.853 <br /> VIII.County/Department Use Only <br /> proved ❑ Disapproved Permit Fe�zj Date l[sued ino Age Signature _ <br /> ❑ Owner Given Reason for Denial $3 7 / II 1 111 va� <br /> IX.Conditions of Approval/Rea ons fo Disapproval 442 7T <br /> Vie-ek- all 5etb4L , f -f-e (61" DtEcEilvEl <br /> NOV 141 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 she r size 2 2 / <br /> Burnett County <br /> SBD-6393 (R0313) Land Services Department <br />