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Department of Safety Count} <br /> �s & Professional Services, w <br /> Sanitary Permit Number(to be filled in by Co.) <br /> pg industry Services Division <br /> 5,4Af -2'�_�b9COL, <br /> Sanitary Permit Application statcTransactionNumbkir <br /> In accordance with SPS 383.21(2),VW,is.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-oumed POWTS are submitted to Project Address(if different thanmaifin address) <br /> the Department of Safety and Professional Services.Personal information you provide nray be used for secondary o�fSa <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. ll `1 `Y^ C <br /> 1.Application Information-Please Print All Information Tot; <br /> Property OHrocr's Name Parcel# D?- Z,^ 39- K-Of- � <br /> �3?FF -t FAIT; V 1 i-.lErle D -aeap- '*r r- 306 <br /> Property Owner's Mailing Address <br /> Q t. 1 Property Location —MX ID 3 462.5 <br /> t C P3 5— gtrN �C Govt.Lot .77 <br /> Ci ,State Zip Code Phone Number <br /> r-I;P �- � U'11� SS3-72 �r;s, Section <br /> 11.Ty'p f Building(check all that apply) Lot# T 01 1 N R 144 E o <br /> C� orl�2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number Cl Village of <br /> A(Town of /`v S , <br /> Ill.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable online A. Check one box on line B.Complete line C if <br /> applivable. <br /> New System ❑ Replacement System p. ❑Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B' ❑holding Tank 14In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design ❑Other'rype(explain) <br /> (conventional) <br /> C- ❑Renewal Before 1 ❑Revision ❑Change of Plumber ❑Transfer to New Owner .ist Previnus Permit Number and Date Issued <br /> Expiration <br /> 1V.Dispersal/Trcatment Area and Tank Information: <br /> Design Flow Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf System Elevation <br /> i„'K4 644 ;Re 4!!�/•6, z� 0 <br /> Capacity in Total #of Manufacturer y <br /> Tank Information Gallons Gallons Units <br /> Ncry T'unks lNisting^ranks 4 03 <br /> n�/� /��y� � A. U tlr <br /> Septic...n.a�:;�k.. � <br /> Dosing Chamber <br /> V.Responsibility Statement-1.the undersigned,assumapAr"llon4illipfor installation of the POWTS shown on the attached plans. <br /> Plumb s Name(Print) Plum s ignauue MP MPRS Number Businese Phone 'umber <br /> �n /3Q�GZ 7i� 3L 199� <br /> Plumber's Address(S cet,City,State,Zip Code) <br /> 14,00 <br /> VI.CountyiDepartment Use Only <br /> Approved O Disapproved Permit Pe Date Issu Issuing Agent Signatu <br /> ❑Owner Given Reason for Denial S 31619 12qrNq <br /> Conditions of Approval/Reasons for Disapproval <br /> A�- �e,�x�•E,� sas �" <br /> qC <br /> nd <br /> LJ <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 W x On in site <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />