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'AT�rrr Department of Safety county <br /> � t ° +4- <br /> �_ & Professional Services, Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division <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 Services.Personal information you provide may be used for secondary -'QX It) 1 933 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I.Application Information—Please Print All Information (Zobc. )Zd <br /> Property Owner's Name Parcel# <br /> 01OWL &nscn 07-oo4-2-38-l4-09-Z 03-000-01100 <br /> Property Owner's Mailing Address Property Location <br /> 7 <br /> 7 1 7 Cr L Govt.Lot <br /> City,State Zip Code Phone Number <br /> Stiote ..re w SS/o�G o-oaR 8- 8 7 69 <br /> va, /, Section Q� <br /> II.Type of Building(check all that apply)/ Lot# T 32 N R E or <br /> J(l or 2 Family Dwelling—Number ofBedroom C✓ Subdivision Name <br /> `\\\ Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> No Town of D44 rt/'S <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. <br /> New System ❑ Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B. Holding Tank ❑ In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑Transfer to New Owner ist Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatn Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 100 1 --- <br /> Capacity in Total #of Manufacturer :? <br /> Tank Information Gallons Gallons Units U S F y <br /> New Tanks Existing Tanks a p a <br /> 4 U in y ii C7 P- <br /> Septic olding Ta <br /> 2�0 2000 1 (.J�e�cr <br /> Dosing Chamber <br /> V.Responsibility statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si nature MP/MPRS Number Business Phone Number <br /> L.►ko T-iereson o.? 7/5 4-3- NIf <br /> Plumber's Address(Street,City,State,Zip Code) <br /> O —inj-Y0-to/ l9�^C r (yt.r�fbu�fr C.� <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Datc Iss ed Issuing gent Signature <br /> ❑Owner Given Reason for Denial $ 3 6 a� 9'113 JSZ3 <br /> Conditions of Approval/Reasons for Disapproval <br /> Ktt+ CLLX S.e+Ua c,LS C4 1 V 2� 15-2 <br /> 25 <br /> Du/ S(-a L - ►1JX&t-c4 an pro+ 6Yi LA,tn. S D <br /> c"p 1 12023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x]�"Inci in size <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />