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Industry Services Division <br />County !Jt tt' 11 <br />r� li'i <br />s � <br />' <br />1400 E Washington Ave <br />S itary Permit Number (to be tilled in by Co.) <br />P <br />P.O. Box 7162 <br />�SN - 19-27 6 1 q <br />�x; <br />� f <br />Madison, WI 53707-7162 <br />C <br />Sanitary Permit Application <br />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 <br />Project Address (if different than mailing address) <br />the Department of Safety and Professional Servies. Personal infonmation you provide may be used for secondary <br />Y3 �6 <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats. <br />I. Please Print All <br />Application Information - Information <br />Property Owner's Name <br />f5 /ye�b�,.t <br />�� l 03 (o"� " _ -T _ �_ S /� <br />,ja <br />5-77-6d00041 <br />Property Owner's Mailing Add <br />Address <br />Property Location <br />/� <br />P6J30 �1/. 14/ta th 5f, 0-' I o O <br />/�/ <br />Govt. Lot <br />%, /<, Section 3(, <br />City, State <br />Zip Code <br />Phone Number <br />f i W&fl ev IJ A/ <br />,ctrcle one <br />T O N; R <br />11. Type of Building (check all that apply) <br />Lot # <br />® 1 or Family Dwelling -Number of Bedrooms <br />/6 ¢ /7 <br />Subdivision Name <br />B lock # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned -Describe Use <br />❑ Village of <br />CSM Number <br />Town of (414 ?O 0 <br />III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A, <br />❑ New System <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑Permit Renewal <br />❑Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Owner <br />IV. Type of POWTS System/Component/Device: (Check all that apply) <br />Y�'or Pressurized In -Ground ❑ Pressurized in -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ Floldtn Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dis erSal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application Rate(gpdsf) <br />Dispersal Area Required (at) <br />Dispersal Area Proposed (st) <br />System Elevation <br />(o0 <br />9°t <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />o <br />y <br />New Tanks <br />Existing Tanks <br />c <br />0 <br />41 <br />Gn <br />w C7 <br />a. <br />a, U <br />Vr <br />Septic or Holding Tank <br />7JI 0 <br />Dosing Chamber..`9-1— <br />t <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signatu e <br />MP/MPRS Number <br />Business Phone Number <br />R/ c /c %�o /�, •� s <br />% / <br />d,� s-�� <br />7�s - ��6 - IS-7 <br />Plumber's Address (Street, City, State, Zip Code) <br />VIII. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fep <br />°D <br />Date Issued <br />Issuing Agent Signa <br />❑ <br />g3�S <br />(.� <br />R <br />Owner Given Reason for Denial <br />I <br />A DO <br />IX. Conditions of Approval/Reasons for Disapproval <br />J.S.SL,,-e� i0/z783 <br />Burnett County <br />Land Services Department <br />TI Xc h Zg63 <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 it-, x 11 inches in size <br />SBD-6398 (R0313) <br />