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Saien and Bwldinei Dnision C'nuu. <br /> _III Nk 11'a)hmcam Arc. P O Boxy 71 n_ &r�e1L r <br /> �mentconsin Il ladlson. kk 1 370' - ?10_ jan Prnnn \u n iheI leobe Idled in b.laDeparof Commerce (608)2ho-315I �5 7*5 <br /> Sanitary' Permit Application <br /> Stale Plan ° "°other <br /> In accord with Comm 83-'I,1C is. .Adin Code,personal ml}annaton you pros ode f N <br /> may be uoed Ibr secondary purposes Pnxacy Law.s I i 1111 Nml v , <br /> I'ro)ea AJJrcss iddn fercnl than matting aJdresil 1 <br /> I. application Information-Please Print:UI Information J <br /> a A7g/a9 S9n0Q it <br /> Property Ou ner's Name <br /> Parcel a Lot a Hlock y <br /> SYe✓c f'�fta, sen Ids - ualhS=Oil 4D0 <br /> Property Owner's%lalling AJdrcss <br /> Property Location <br /> 3d.,3S �bSewooc� /h N C� � <br /> Cny.Slate LP Code Phone Number . Section ods <br /> fl moud1, /vtN SS''/4/ '763-SSS -99d'7 mcle s3) <br /> r11.Type of Building(check all that apple) T & N. R �?Eu w <br /> ICP I or 2 Farm ly Dwelling-Number of Bedrooms .3 Subdlslswn Name CSM ;Number <br /> ❑ Public Commercial-Describe Usc <br /> ❑Slate Owned-Describe Use ❑Caty_❑VIIlage&Township of Ae_kJOn <br /> Ill.Type of Permit: (Check only one box on linea. Complete line B if applicable) <br /> A <br /> 'cY New System ❑ Replacement System ❑ Treatment Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Pcrnw Renewal ❑ Permit Res bion List Previous Perron Number and Date Issued <br /> ❑ Change of ❑Permit Transfer to New <br /> Before Expiration Plumber Owner <br /> 6�Il+k.Ti, a of PO%%TS System: Check all that a h) <br /> eyl Non -Pressurized In-Ground ❑ Mound>?a in.of suitable sod ❑ Mound<24 in.of,wtable sod ❑ At-Grade ❑ Single Pass Sand Filter LJ <br /> Constmeted%etland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filler ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Syntheiw M1ledw Filter ❑Leaching Chamber ❑Drip Line ❑Gracel-less Pipe ❑Other(cxplaml <br /> �'. Dis ersal/Treatment Area Information: <br /> Design Flow Igpell Design Sod Application Rate(gpdsl) Dispersal Area Required Ist) Dispersal Area Proposed(st) System Elevation 3• <br /> 7 (0 43 �o[f 8 xa pp.r <br /> ll.Tank Info KGallons <br /> acity in Total Number /pwsr be�,7 <br /> Manufacturer Prefab Site Steel Fiber <br /> Gallons of Units Plastic <br /> ExistingConcrete Constructed Glass <br /> Tanks <br /> Sapuc or Holdmg TankAerobic Treatment I:nit <br /> Dusmg Chambr i— , �"ff a <br /> �0Q <br /> N1 I. Responsibility Statement- 1,the undersigned,assume responsibility for installation of the P0%t TS shown on the attached plans. <br /> Plumber's Name IPnnn Plumber's Signature MI'MPRS Number <br /> Business Phone Number <br /> RIe-1e /'10 Im IzIAJ �dS`$S/ 71s-- <br /> Plumber a Address ISuea,Coy,State,Zip Code) <br /> ,,)t -77(0 /7�w 3S Wt 4s"`t✓ W-,- _rt 8 t3 <br /> I'll CountviDe artment Use Only <br /> approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu.ng A gnature(No Stamps) <br /> r <br /> C1 Owner <br /> Fee) k 25o Owner Given Reason for Denial r <br /> 1\.Conditions of Approval/Reasons for Disapproval <br /> APR 2 2M <br /> BURNETT COUNTY <br /> ZONINn <br /> Attach complete plans(so the County tint))for the system an paper not less noon 81.2 x 11 inches in so <br /> SBD-6398 (R. 01/03) <br />