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i-'t;:>'..2-ritAi„ County <br /> '4:t, Industry Services Division is ti k el e <br /> v D; �.6' 1400 E Washington Ave <br /> ,= 9 Sanitary Permit Number(to be filled in by Co.) <br /> �, tia P.O. Box 7162 <br /> 'tib ' ,rX, Madison, WI 53707-7162 <br /> SAN-.2D—Pell <br /> State Transaction Number <br /> Sanitary Permit Application 1�8 0 <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Co _ <br /> isrequired 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 Servies. Personal information you provide may be used for secondary ����i <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. �Pat <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name greelp�d �IA 1_eet0 16'- 07—S.(3 <br /> 6:04%e r !/j0rrlhdee1/47 Sgo- O'r3coo <br /> Property Owner's Mailing Address Property Location # 14.245 <br /> ot 88'6 x'61• E yaw Vier Rd <br /> Govt.Lot <br /> City,State Zip Code Phone Number y, y,, Section 7 <br /> k/e11.5 4'e r (4J'7-- S-y e9 3ctrcle one <br /> T y� N; R E oillebto <br /> II.Type of Building(check all that apply) Lot# <br /> PI 1 ort Family Dwelling-Number of Bedrooms ; 33 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> CI City of <br /> CSM Number ❑ Village of <br /> ❑State Owned-Describe Use <br /> 01.x'WS i,A, 3 El Town of Da(C/Ail <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System y ❑ Replacement System R Treatment/Holding Tank Replacement Only CI Other Modification to Existing System(explain) <br /> B ❑ Chang ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑ Permit Revision Chancre of Plumber <br /> Before Expiration Owner <br /> IV.T se of POWTS S stem/Coma onent/Device: (Check all that a..I ) <br /> Is.,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..Dispersal/Treatment Area Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 — — <br /> VT.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o o <br /> u <br /> New Tanks Existing Tanks o 1 Y m a <br /> a.U ti cn w V a. <br /> Septic or Holding Tank poo SW / ---4-ie a w <br /> Dosing Chamber.. O ; :), <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 NIP/MPRs Number Business Phone Number <br /> /2/C-/r a. d /d /t ins /Zc- __.f olds 8J l lir 5G6— 4J"S 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 02776o //o.7 ,k.s— pr_e65/,-., hJ 5489.E <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Perm it�Fee Date su-, suing A.ent Siena 0 7 / <br /> 00 <br /> ❑ Owner Given Reason for Denial $✓`•` .1 /c 2020 ���/� <br /> IX.Conditions of Approval/Reasons for Disa proval <br /> r r 'L;!' . - _ <br /> 3-25 <br /> coSF%K2, •ik e 1 C • 3: . D QV <br /> * bwr .4. k vpiraolect if 54-rActrAyts O. PraPait tilted <br /> .2 ►ridnoo.6t►c_ , it <br /> - . . <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/?s 11"ch.i i i siz <br /> Burnett County <br /> SBD-6393(R0313) Land Services Department <br />