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VIV I.,VIVlrv tt_tvvv. ..... <br /> Safety and Buildings Division Cin <br /> 201 W. Washington Ave.,P.O.Box 7162 ll h e <br /> 84sconsin Madison,WI 53707 -7162 Site Address <br /> Department of Commerce a 4a'kei Pri✓ +L <br /> Sanitary Permit Number <br /> Sanitary Permit Application 2 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision L4� 5 73 <br /> my be used for secondary ses Privacy Law,s15. 1 m <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Numbe o32 9 2 3 v o SSaO <br /> ,8j/l /— QSrIc i-<Zf La <br /> Property Owner's Mailing Address Property Location <br /> D. /3o O " <br /> L sa7T N.R <br /> City,State Zip Code Phone Number Lot Numbe Black Number <br /> Subdivision Name CSM Number <br /> Poch �e !�/,s . S�fB o 5 im V. <br /> II.Type of B 'd' g(check all that apply) ❑City <br /> 91 or 2 Family Dwelling-Number of Bedrooms ❑Village <br /> ❑Public/Commercial-Describe Use ,Township 'J 1 <br /> ❑State Owned Nearest Road <br /> Ld,k r)Pe- <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> For County use <br /> A tQ� <br /> 1; i New 2 ❑ Replacement System 3 C1Replacement of 6 11Addition[o <br /> S stem Tank OW Eris' S stem <br /> B. El Check if Sanitary Permit Previously issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 9 Non—Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Welland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 3o❑Other <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area SOB Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rafe(Gals./Days/Sq.F[.) (Min./Inch) Elevation <br /> 300 `f.29 � . s . 7 _ y6 � 7 � �/9, <br /> 6 /SA <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tann <br /> Dosing Chamber <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 MP/MFRS Number Business Phone Number <br /> / Qanto�� A o2 v- 9.1 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 6S`4 je- gelt <br /> VIII. Count /De artment Use Onl <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) <br /> Approved ❑ Disapproved Surcharge Fee) 41 <br /> ❑ Owner Given Iridal Adverse ✓Rf/�'t).1t i � �I `J�� <br /> Determination <br /> IX. Conditions of A roval/Reasons for Disapproval <br /> PP <br /> JUL 262007 <br /> BURNETT COUNTY <br /> Attach complete Plane(to the County only)fre the syrt m paper not lean Wan 8112 x 11 inches in size <br /> SBD-6398 (R. 05101) <br />