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y,�'.a a ;.31 County <br /> r- '` :,:+ Industry Services Division LSLt.,e y'e79- <br /> ;-4r` DS ., 1400 E Washington Ave Sanitary Permit Number(to be tilled in by Co.) <br /> ,' `' P . <br /> ' , P.O. Box 7162 <br /> , <br /> ✓� y Madison, WI 53707-7162 sprtJ-ZO-o/40. , > csT-c o-CI 9 <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 028 f0 <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 �� <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> 07`04,!-d-3s-/J-d7-S /s <br /> ��l<< ?G+ofr sow - 3'sy. 'PA 1oov <br /> Property Owner's Mailing Address Property Location .4 z'!it'd <br /> /v/o etc/ /1/• .SAD re Or Govt.Lot #2952Z 240Z4 <br /> City,State // Ziip�Codee Phone Number y, /,, Section pt 7 <br /> �j v N•f"S�O (4...5' 1A-i j �/ /n3 icircle one <br /> H.Type of Building(check all that apply) Lot# T 38 N; R / E or <br /> N I or 2 Family Dwelling-Number of Bedrooms 3 /2 a. /4/ Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> CSM Number El Village of <br /> EJ State Owned-Describe Use <br /> QTown of Wee, /Zlve✓ <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New System , J Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B• ❑ Pennit Renewal ❑Permit Revision ❑ Change of Plumber ❑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 /> ,®Nbn Pressuiized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Ffoldm>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 /> WSJ . 7 _ 4 v3 8G ti gs o <br /> VI.Tank Info Capacity in Total #of Manufacturer y <br /> Gallons Gallons Units o <br /> N <br /> New Tanks Existing Tanks t o `e' 2 ro <br /> c, U cn ti in tr C7 0. <br /> Septic or Holding Tank /000 /01 1/ ,,p{ <br /> Dosing Chamber.. o / "" I`✓�� A <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 Si atur MP/MPRS Number Business Phone Number <br /> /z/4 k /lo , /h .S T j/j -/ .5-£ -, 7/3 846—W-5-7 <br /> Plumber's Address(Suet,City,State,Zip Code) <br /> • <br /> 6,17760 , y _?- - lei-e6 i- 1,,�: S''s' <br /> VIII.County/Department Use Only A <br /> Approved ❑ Disapproved <br /> Permit Fee Date sued I • rent Signature <br /> ❑ Owner Given Reason for Denial <br /> 3$. 9�s/ozo _ % _ --1 <br /> IX.Conditions of Approval/Reasons for Disapproval CY E <br /> ' et L <br /> xl tstutt - s wt{- log P« dor AYr.t',ti #a be &tatro J <br /> r------ <br /> fit am s pa+►tcla. *d 291/1/ ei 29$22, W 29124 r� <br /> • ER ; , SEP 1 4 2020 [.....:,,h1 <br /> !d ura�'�,�cc +Tiwtks )1440# 144es. IL <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t/?x ,l inchedin sizy_ <br /> Burnett County <br /> Land Services Department <br /> � <br /> SBD-6398(R0313) j 'P �a01 "v im <br />