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r,.i'"tia^.ri,,,.'=3y County 7 <br /> r<,;.; '�':r! Industry Services Division j3t..✓n.e - <br /> e ` i .t" 1400 E Washington Ave <br /> ,� ,� � �� 9 Sanitary Permit Number(to be tilled in by Co.) <br /> ' O P.O. Box 7162 <br /> ' s'l , -4/. Madison, WI 53707-7162 <br /> ;,; J C.51-_2o T2 GZF39/ <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 <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 Servies. Personal information you provide may be used for secondary i y 40 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information—Please Print All Information S. 51)ore ie0t' <br /> Property Owner's Name Parcel# <br /> j (1 lieSscl rote- Ord - yotys- CS3 O *ttfi" <br /> Property Owner's Mailing Address Property Location <br /> $`ti- 9r4.,d l e y Dr;ge-e <br /> Govt.Lot 5-- <br /> City, <br /> City,State Zip Code Phone Number / y, Section 35— <br /> )Y tA <br /> f)Ytn p(f 0 v1 lnTf- 51-i D 16 (circle one <br /> T 4" N; R /S E or <br /> II.Type of Building(check all that apply) Lot# <br /> I or2 Family Dwelling—Number of Bedrooms 04. Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> CSM Number El Village of <br /> ❑State Owned—Describe Use <br /> 0 Town of J ACICSon <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> B New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Pennit Renewal ❑Pennit Revision <br /> ❑ Change of Plumber ❑Pennit 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 /> A Mon Pressurized In-Ground ❑ Pressurized In-Ground El At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ HoldingTank ❑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 , 7 `0.9 `i5i 90( .51 ii. 93. , <br /> VI.Tank Info Capacity in Total #of Manufacturer u <br /> Gallons Gallons Units o o <br /> New Tanks Existing Tanks V c v Ti 5 <br /> 0 2 <br /> c,U rn ti rn ii C7 a <br /> Septic or Holding Tank 8.410 e:; t t 9 L <br /> Dosing Chamber.. ...sae .00 / GV �f✓rt'- 7 <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> /Z1 G k //m 1 k to s / .e, .,,e1 >v, • eA,0--"8J-7 7/..s= cr6e- `-iis-7 <br /> Plumber's Address(S I eet,City,State,Zip Code) <br /> A 7760 ✓ ,.,,/ 3s Ave6..sfT - / r .S�'5: 7 <br /> VIII.County Departfnent Use Only <br /> Approved DI Disapproved Permit Fee Date Issued Issuing Agent Signature / <br /> --- <br /> ❑0 <br /> Owner Given Reason for Denial S 57ID '/‘• 2 t, Id. <br /> I.C.Conditions of Approval/Reasons for Disapproval - <br /> D ECEOVE --- <br /> SEP 2 8 2020 ._y <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 ihes size <br /> Burnett County <br /> SBD-6398(80313) Land Services Department <br />