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Industry Services Division County <br /> 1400 E Washington Ave A rive,�� <br /> X:. <br /> $ P.O.Box 7162 ry ( yCO.) <br /> Sarita Fwtmit Number to be filled in b Co <br /> �.. S Madison,WI 53707 7162 <br /> Sanitary Permit Application Smote Transaction Number <br /> In accordance with SPS 38311(2),Wis.Adm.Code submission of this font[to the appropriate governmental unit <br /> is-quired prior to obtaining a saniwry permit.Note.Application form for stat"wo d F^v::";S a.c submitted to Project Address(ifdifierent than maiiing 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. Applicadon Information—Please Print All Information /",7 <br /> Property Owner's Name Parcel# -T lG 52-Li I <br /> ew /'i0r, D5^Opl—Ot <br /> Property Owner's Mailing Address Property Location <br /> ze73/Awc Govt.Lot Y__ <br /> City,State Zip Code Phone Number , I <br /> aN / � l� ��30 �+, Section <br /> 1/w ,_(circle one <br /> H.Type of Building(check all that apply) Lot it T N: R 4? E o& <br /> 1 or 2 Family Dwelling—Number of Bcdrooms Subdivision Name <br /> Block <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number Village of <br /> V - Town of '� i <br /> V7 " <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A* ❑New System <br /> y �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 /> Before Expiration Owner I NV' <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) <br /> V.Dis ersoUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total r of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks Q a <br /> c.U ifi m en ti t7 0. <br /> Septic or oldtng T l D®U I-65 <br /> Dosing Chamber <br /> V11.Responsibility Statement-L the undersigned,assume responsibility for lostallat ion of the POWTS shown on the attached plans. <br /> Plun cr's NameX <br /> (Print) Plumber's t ttuc MP/MPRS Ntupber Business Phone Number <br /> T i �5'`�t5-7 7/ -I&-ozoZ <br /> Plumbers Address(Street,City,State,Zip Code) <br /> e( l}vmw Waal �Jeb5ler- V i 5'/69 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signat ue <br /> ❑Owner Given Reason for Denial S 3-15125) 0 I Z1 I ZQ214 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> 4�-76LLow 0J COLLr `1 aid S+a-�e r��u l rey►�e S n <br /> •� <br /> �' IOC -�k4 loccl+t o S Q l-4 q -+e `tf <br /> Attach m complete plans for the s)'stem and submit to the County only on paper net teas than ti is z I fact is fla AUG 2 0 2024 <br /> i <br /> Burnett County <br /> Land Services Department <br /> SBD-6398(R.08/14) <br />