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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> 1 iseonsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Depprtment of Commerce Submit completed form to coup f not <br /> so <br /> [Privacy Law,s. 15.04(1)(m)] ( P county i C.) <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 1 I inches in size. <br /> County State Sanitary Permit Number ❑C k if rev'sion to reviou plication State Plan I.D.Number <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name (� / Property Location e d - � <br /> 100k le— I-e7erS6 SVIAS�I/4,S/3T ?EN,R/�y(ora <br /> Property Owner's Mailing Address Lot Number Block Number <br /> '?r87 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> S LAj . I 6-V6 l <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ Town of <br /> ❑ State-Owned <br /> Nearest Road <br /> ��fcrsOrt Gr <br /> Parcel Tax Numbers) _Zy�'0� <br /> 111.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. N New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) <br /> 1:1 Permit Number Date Issued <br /> A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> JKNon-pressurized In-ground ❑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 Area4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) -"i 9'?,GAO Elevation <br /> 416(N ?66 73 y z e ,5 ?z 9.S. 'lo 7?, a� <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks / <br /> (� 11"40 / &J P,S e(' ❑ ❑ ❑ ❑ <br /> ❑ 11 13 ❑ <br /> OD <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber' atu ps): 1PIZ RS No. Business Phone Number <br /> /son G� - <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only 77 77, <br /> ❑Disapproved Sanitary Permit Fce(Includes Groundwater Date Issued Issui Agen ign o stamps) <br /> KP)/Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination ���� 2 - <br /> X.Conditions of Approval/Reasons for Disapproval: u- <br /> i it <br /> SEP 1 20 <br /> BURNETT COUNTY <br /> SBD-6398(R.07/00) <br />