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r;; Industry Services Division County <br /> '" 1400 E Washington Ave 614 r eti- <br /> =i Is a `,,L. P.O.Box 7162 <br /> $ / Madison,WI 53707-7162 Sanrtary Permit Number(to be filled in by Co.) <br /> ��- /12 <br /> r . <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit GA3/33 <br /> is required prior to obtaining a sanitary permit.Note:Application forms 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. '' S,4k&4 ' <br /> I. Application Information—Please Print All Information /��L� <br /> Property Owner's Name Parcel# C)0 <br /> liji t ke x ;07141c z 070172:4o J )3si s i Ll ocoo <br /> Property Owner's MailingaliAddress Property Location l i i_W44 <br /> 36 LJ e �i K & J Oy Govt.Lot 7 <br /> City,State Zip Codep`� Phone Number <br /> 2 p _ ` / /3 2 <br /> OC4 ll b if r'y V v I 9`-f 0 0 7) -S 7J-) 7 /�' !°'S�!/ %,, SectionloI J <br /> II.Type of Building(check all that apply) Lot# T `�d N; R � E o W <br /> YPPP Y) <br /> KI or 2 Family Dwelling—Number of Bedrooms 2- Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> 0 City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> IfTown of a-a G/soy, <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal ❑Permit Revision ❑Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> V.Non-Pressurized In-Ground 0 Pressurized In-Ground ❑At-Grade 0 Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Deaia.n Flow(gpd) Design Soil Ap tion Rate(gpdsf) Dispersakkrea Required s Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks ti <br /> o Y a <br /> ^� <br /> a.v e. in is. ca <br /> 7 <br /> Septic or Holding Tank <br /> /Dosing Chamber 740 1 t 5 e <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PI ber's Name rmt) Plumber's • attire <br /> MP/MPRS Number Business Phone Number <br /> el ; s s�c , T$' 07? 71 -520-2,3 --- <br /> Plumber's Address(Street,City,State <br /> p Code) <br /> tkil 7O o3 A°ivy L 0 "4 -rreg� W I os?..?? <br /> VIII.County/Department Us On <br /> roved 0 Disapproved PermitsFe 00 Date suetyumggent S e <br /> 0 Owner Given Reason for Denial $✓I)• 451&3'o <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> v $tis+ m, 2444.44 K "tam Ire tot Of gdove 91.'5✓' . <br /> c-441.1co3t <br /> isfiolls Sl�Skt.•t it) wlolude�lte( per SPS, 383, s�aSc'_° <br /> 4 E <br /> ,EcEOVAI <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 1 n size <br /> JUN 2 4 2020 <br /> SBD-6398(R.08/14) Burnett County — <br /> Land Services Department <br />