Laserfiche WebLink
Safety and Buildings Division County <br /> Visconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 ;' GL h/v e <br /> Madison WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Lew,sl5.04(1 xm) Project Address(if diffeemnt t}ran mailing address) <br /> L Application Information-Please Print All Information a9sa"7 r6k h6l <br /> Pmpeny Owner's Name Parcel# LAA# Block# <br /> R and F. Fox ora-Yda-o3- d0 <br /> Property Owner's Mailing Address Property Location <br /> aaai;, oe-lCta.-sect� p <br /> City, Zip Number Ay—V,rL�, Section <br /> A� lip'Code Phone <br /> //!G v'� Vr•e�"'t /' ✓ s'il2 763- 316 —otY3 ncle <br /> 11.Type of Building(check all that apply) T N; RE <br /> W1 or 2 Family Dwelling-Number of Bedrooms <br /> 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> El state Owned-Describe Use ❑City_❑village Township of �- <br /> G <br /> 111.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. <br /> ❑New System Replacement System ❑Treatinent/Holding Tank Replacement Only El Other Modification to Existing System <br /> B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T e of POWTS S stem: Check all that apply) <br /> Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mould<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Send Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑ Aerobic Tteabnent Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Grevel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: _ , <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsf) Dispersal Area Required <br /> U r � (st) Dispersal Proposed(sf) S stem Elevation 6 G <br /> 1 -6 `loo � �.�r W. <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab S1 Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> optic olding Tank Oa V <br /> S aw JC <br /> Aerobic Treehnent Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume 4ponsibility for installation of the POWTS shown on the attached plans. <br /> Plumbm's Np ne(Print) / Plum stgn a WA`/MPRS Number Business Phone Number <br /> 9Ar7 ��,,er JI"� a3�a7 so 7I S-- Y1� -a 73f— <br /> Plumber's dress(Street,City,State,Zip Code) / <br /> . v c Jl ' !C Com. •$�5/ 3 <br /> Coun /De artment Use Only <br /> Approved E)Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin n ignature o Stamps) <br /> Surcharge Fee) L� <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ;ala <br /> Atlach complete plans(to the Coesty,only)for the ayam tm paper at Iran than 9 SER 2 7 20U51 inchm m tis <br /> BURNETT COUNTY <br /> SBD-6398 (R. 01/03) ZONING <br />