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:". Industry Services Division County At <br /> 1400 E Washington Ave ` akeik <br /> ,Js; .®S P P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 5A0..;4' II. <br /> n`,..;0, I* 6 , a0-43 <br /> ZOr <br /> Sanitary Permit Application State Transac2tio'�n Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit &A.3Number <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 /> pI. es in accordance with the Privacy Law,si 15.04(1)(m),Information <br /> Stats. 2' 5 �,/`n �, <br /> I. Application Information—Please Print All Information 6 "/,w" P <br /> Property Owner's Name / Parcel# Xing <br /> d <br /> Property Owner's Mailing Address Property Location <br /> 128 OZ ,U rth Wei Govt.Lot <br /> City,State '_ f ZipipCode Phone <br /> onNuumbber y� v,, 5 W y,, Section Z3 <br /> et w/�� ✓ r8/(/ 7i5'417-04171f ! irrcleone <br /> T N; R �-( E o� <br /> II.Type of Building heck all that apply) � Lot# <br /> 11 or 2 Family Dwelling-Number of Bedrooms C Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> CSM Number 0 Village of <br /> ❑State Owned-Describe Use t <br /> tirTown of Wre4(24k4 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Di New System y 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of PlumberList Previous Permit Number and Date Issued <br /> 0Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ffir Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 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 /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 75^C) ( I 107/ /0 !/ T92.d .1WI <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units vo <br /> New Tanks Existing Tanks .`4 '' 0 C' , u m <br /> c.U in H rn ii". 0 a. <br /> Septic or Holding Tank aV/ jg�r.J / ✓ ✓V Y <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plu cr's Name(Print) Plumber'- ,nature MP/MPRS Number Business Phone Number <br /> Atm T 1/4A� � r 8679 51-1 7/5--sa-62o2 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6136,1 ,v� w tie i/ cive6 v.- 511139 3 <br /> VIII.County/Department Use Only <br /> OZ,ppprovcd 0 Disapproved Permit Fee Daty Issue Fgent Signature <br /> $ 3�S °0i�l�ioaoN,,�ti( <br /> 0 Owner Given Reason for Denial . ....-,--- <br /> IX.Conditions of Approval/Reasons for Dissup roval <br /> tDtatt4r'tlet "west Ilii. 5041 frtut4 well. <br /> 331/ 1/e. per “Al 9 2S s 41-25152 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t12 a jar s in size <br /> APR 2 1 2020 J <br /> SBD-6398(R.08/14) <br /> Burnett County <br /> Land Services Department <br />