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z r.•." County <br /> 0 `.;... ``t„s Industry Services Division //ti r �7� <br /> 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> P.O. Box7162 <br /> r,� Madison, WI 53707-7162 b4(c3�j'jg <br /> = _w -2 2 <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 8W 5ll _r"TD <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. w o r til k IZ(� H b <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> _ -muff o7�6xG.L�Nb-1 '��07 .�000 <br /> Property Owners Mailing Address Property Location <br /> a�s0 O L /710� Govt.Lot <br /> City,State Zip Code Phone Number /, y,, Section <br /> /. t .ev (circle one <br /> II.Type lt of Sing(chec all k apply) Lot# T y� N; R 7 E o� <br /> � Ior2 Family Dwelling—Number ofBedrooins .3 Subdivision Name <br /> B lock# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> XTownof LAk1iOv� <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other b[oditication to Existing System(explain) <br /> B. ❑ Permit Renewal ❑Pen-nit Revision ❑Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type.of POWTS.5 stem/Com onent/Device: (Check all that apply) <br /> NOR PiK t rued In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ €{oldma Tack ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V') ersal/Treatment Area Information: <br /> Design Fiow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st)M!! ,g <br /> 4S'"a . S 900 9a0 <br /> VI.'Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks ExistingTanks a E <br /> Septic or Holding Tank A00 t4 <br /> Dosing Chambzr_ ! 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 Signature MP/MPRS Number Business Phone Number <br /> /� lGIG iy ,�/ �h5"frSl 7�s fGG- �i' <br /> A <br /> Plumber's Address(S eet,City,State,Zip Code) `, \ <br /> 77ho i„t 3 S Gv�� ,cam wl <br /> VIII.County/Department Use Only <br /> Approved El Disapproved Pen-nit Fee Date Issued uing Ag t Signatur <br /> ❑ Owner Given Reason for Denial <br /> $ � a-s 7/;I <br /> laa - t <br /> IX.Conditions of Approval/Reasons for Disap royal 2 <br /> �e�� c4 (� <br /> See Revision Ult -7I890 <br /> JUL 2 0 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in 11 inches i size $ t�a <br /> Burnett County <br /> Land Services Department <br /> SBD-6398 (R0313) <br />