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Sanitary Permit Application Safety&Buildings Division <br /> Visconsin <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [privacy Law,s. 1 he us d for (Submit completed form to county if not Q; <br /> state owned. <br /> A//ttach complete plans to the coup co only)for th stem,on a er not less than 8-1/2 x 11 inches in size. <br /> County me T State Sanitary Permit umber Ch ' rev oon to previ us ap 'cation State Plan 1.D.Nu ber <br /> I.A lication Information-Please Print all Informatio �1 d Location: <br /> Proper[(1v Owner Name Property Location <br /> �/ !Yl '�S S �?Pa nt k l4 W/4 S I T 3 N, W <br /> Property Owner's Mailing Address /A / ,I Lot Number Block Number <br /> �I t ePil/K Wfi iJ W <br /> City,State Zip Code _F_Phone Number Subdivision Name or CSM Number <br /> t Lo G 6 1 7o -0 <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Town of <br /> ❑ Public/Commercial(describe use): �[ / <br /> ❑ State-Owned Man 1 el <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest xoa // <br /> G1 eft YL-- <br /> A) 1. ❑New System 1 2. JEReplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Onl) Existing S stem — '-1 —o (0 O <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> ❑Non-pressurized In-ground pa Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> ol.sVf/sD q sa I g g C'3 /01"s- <br /> VI. <br /> I.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> X d0 I I 020WOo ❑ ❑ ❑ ❑ <br /> VII,Responsibility Statement 100 <br /> I,the undersigned,assume res on ibilitAfor installation of the POWTS s own on the attached plans. <br /> Plum e Name(p nt Plum is Signature(n s s): MP/MPRS No. Business Phone Number <br /> 1 '97/r 6 <br /> Plumber's Address(Street,CitSr,State,Zip Code) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Pe it Groundwater Date Issued Issui Aenti tamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) jy ! <br /> �— Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> I <br /> SBD-6398 R07/00 L n) 001 OU <br /> BURNETT COUNTY <br /> ZONING <br />