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County Industry Services Division <br /> 6' � 1400 E Washington Ave <br /> 1�! <br /> P.O.Box 7162 <br /> 1rt� � S j rj Madison,WI53707 7162 Sanitary Permit Number(to be filled in by Co.) <br /> C - --7 �fe53 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383Z1(2).1Vis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit.Note:Application forts 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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information (Cut[ <br /> Property Owner's Name Parcel# <br /> /�/�t a VCYwS� o lz•�-�t�-ls��-5-�5�15-�lBo� <br /> Property Owner's Moilin/g Address Property Location <br /> Z li t7 t 7 0 N/t v l 0 Govt.Lot <br /> City,S Zip Code Phone Number 3 <br /> N t f t CCU /� /. Section <br /> Vv �� J"v% rcle e) <br /> II.Type of Building(check all that apply) Lot T_�N, R�Ek <br /> I or 2 Family Dwelling—Number of Bcdmoms 7 Subdivision Name <br /> Block g <br /> ❑Public/Commercial—Describe Use ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> $Tonm of �ZiGr/;01"J <br /> III.Type of Permit: (Check only one box online A. Complete line B If applicable) <br /> A* ❑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 IList Previous Permit Number and Date Issued <br /> Before Expiration 11 Owner V y 7 l i�I I l l 9-7 5 <br /> ,,IT�V//.Type of POWTS System/Component/Device: Check all that a i <br /> L7 t <br /> Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil 11 Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersal)Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Re4uired(sf) Dispersal Area Proposed(sf) System Elevation <br /> 3cd I - 7 yzei ysz I if7# �� � <br /> VI.Tank Info Capacity in Total of Manufacturer <br /> Gallons Gallons Units o'g n <br /> New Tanks Existing Tanis <br /> a,U in iX m iz 0 a <br /> Septic or Holding Tack 75- <br /> Dosing Chamber S� L�,ry, 7 t� w <br /> VIJ.Responsibility Statement-L the undersigned,assume responsibility for hastallation of the POWTS shown on the attached plans. <br /> Plut cr's Name(P nt)W-it/ <br /> Plumber's tare MP/MPRS Number Business Phone Number <br /> Plumber's Address(Street,City.State,Zip Code) <br /> li t AOA w 1 k /go/ (41ebg/eo- V, 5�(69 <br /> VIII.CounylDepartment Use Only <br /> Approved ❑Disapprovcd Permit <br /> GFee Dot701202-L4 <br /> ued Issuin Agent Signature <br /> ❑Owner Given Reason for Denial S��✓ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> chow a� cam/ glld Soak the lithe#XeI5 M Q <br /> Attacb to complete plans for the sSstem and submit to the County only on paper not less than 8 itt 111 .} <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R 08/14) <br />