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Industry Services Division <br />County <br />Ot�rvl <br />1400 E Washington Ave <br />9 <br />P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />L�a <br />Madison, <br />3RM - t a l -34 I D 7 <br />WI 53707-7162 <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 information you provide may be used for secondary <br />in Law, <br />8 to 15— <br />purposes accordance with the Privacy s. 15.04(I)(m), Stats. <br />/ <br />L�� /�l� <br />I. Application Information — Please Print All Information <br />E• /3ti SS <br />Property Owner's Name <br />L®tti{( Jrevev's�� <br />Parcel # 7— j 3 S O.� <br />c�-r-� d? <br />aaaoeo <br />Property Owner's Mailing Address <br />Property Location <br />lyo17 a eat ci, ,v <br />Govt. Lot Ll <br />%, /<, Section 1 3 <br />City, State <br />st <br />Zip Code <br />Phone Number <br />lr wit-e�� <br />i /1'11v <br />s <br />(circle one <br />T L110 N; R 17 E o& <br />II. Type of Building (check all that apply) <br />Lot # <br />I or 2 Family Dwelling —Number of Bedrooms <br />Subdivision Name <br />❑ Public/Commercial— Describe Use <br />Block # <br />❑ City of <br />❑ State Owned —Describe Use <br />❑ Village of <br />CSM Number <br />TOWn of (� `i /OM <br />rmit: (Check only one box on line A. Complete line B if applicable) <br />stem <br />r <br />Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />Renewal <br />❑ Permit Revision <br />❑ Change of Plumber <br />❑ Permit Transfer to NewList <br />Previous Permit Number and Date Issued <br />iration <br />Owner <br />IV. Type of POWTS S stem/Com onent/Device: (Check all that apply) <br />Non Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ fvfound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />❑ HoldingTank ❑ 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 (s fl <br />Dispersal Area Proposed (st) <br />System Elevation <br />VI. Tank Info <br />Capacity in <br />Total <br /># of <br />Manufacturer <br />Gallons <br />Gallons <br />Units <br />u <br />o 0 <br />0 <br />New Tanks <br />Existing Tanks <br />c`, U <br />in <br />m <br />cL V <br />a. <br />Septic or Holding Tank <br />Dosing Chamber .. <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number <br />171 t /c f% 1Z1$1s d ��-�s / 7is- SGG-yes ? <br />Plumber's Address (Street, City, State, Zip Code) <br />s7�'Cr,71 <br />VIII. Coun /De artment Use Only _ <br />Approved <br />❑ Disapproved 7.i.1373 <br />ermit Fe � <br />Date Issued <br />Issuing Agent tgnatur <br />❑ Owner Given Reason for D <br />' <br />1 2 /DA=g7-- <br />IX. Conditions of Approval/Reasons for Disapproval <br />APR 2 5 2019 <br />J!� <br />Burnett County <br />Land Services Department <br />Attach to complete plans for the syste submit to the Coua1 paper not less than 8 1/2 x 1 l inches in size <br />1 //3jj�,, <br />QR FI_910o f�J "�7�� <br />