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Industry Services Division County <br /> 1400 E Washington Ave �(i(c ne " <br /> P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> a Pt Madison,WI 53707-7I62 � (� , 12- <br /> eqwl3 - 113 5�86 <br /> Sanitary Permit Application State Tiansaction 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 slate-owned POV✓TS 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 )2.3 e,8 6e"� R4 z <br /> purposes in accordance xvith the Privacy Law,s. 15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information "'t <br /> Property(hvner's Name Parcel# <br /> d{ -5o ri 07-o39-Z - 37-/f z% <br /> Property Ow&1 s Mailing Address J Property Location i wy ,D: 2'4 1 51 <br /> t-L.-je, O (1011-n � R�1 Govt.Lot <br /> City,State 'I 1 Zip <br /> /code <br /> ! Phone Number y, 14, Section 7— <br /> le one <br /> II. T-..,e-a f P..a ( llecr, n.r .. i,.�. T r# F,o� <br /> JN� v� wwws��awn u.�that appl.7I <br /> �1 or 2 Family Dwelling-Number of Bedrooms <br /> 4. Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> V I P 3/O 2 Town of Tr c(l G<�� <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 Modification to Existing System(explain) <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> tsefore Expiration Uwner <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 Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑Other Dispersal Component(explain) 'Pretreatment Device(explain)—vLA, EtaE <br /> V.Dis ersal/Treatment Area Information: <br /> n <br /> i iJr. a� "'�rSai __- -' ' _� <br /> .gn n <br /> r <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units p o ,b, U <br /> o U <br /> New Tanks Existing Tanks � o B � Y •a a <br /> Septic or Holding Tank u/Od r--Y^ <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume res onsibility for installation of the POWTS show the attached plans. <br /> Plumber's Name(P nt) Plumber's gn rc j� MP R Number Business Phone Number <br /> t �'i•� gwi0✓�Iti �i`4,/�: �5©a3651-713-533-141 <br /> Plumber's Address(Street,/C,ity.State.Zip^Co+/de) ( �; <br /> 1i71CJ0 Z JO t� Al T <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Da Issued [� Issuin Agent Signature <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval �R t <br /> Mtd alb Rftkt C C' I M C <br /> �blr R-) I I In I <br /> day G1,1,( (UafYI S-{ k nj Inai�gl& <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 1 r i <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) <br />