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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 tf rN e)I-) <br /> "- <br /> Madison, <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> (608)266-3151 4w 16) <br /> Department of Commerce <br /> Sanitary Permit Application Stere Plan I.D.Number RJ <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Pnvacy Law,sl5.04(I)(m) Project Address(if different than mailing address) <br /> I. ApplicationInformation-PleasePrintA ornatin #� pit <br /> Property Owner's Name Parcel# Lot# Block# <br /> r4a-01(0 <br /> hN u or-goo <br /> jo9 <br /> Property Owner's Mailing Address Property Location <br /> Z/S ) eIP70AJ _614, ,., section�D <br /> Ginty,State Zip Cale Phone Number <br /> V nl/v 5 "o6D C7 QQ-/7/y mrcle <br /> R.Type of Building(check all that apply) T y� on Name <br /> or <br /> 1f 1 or 2 Family Dwelling—Number of Bedrooms Z— Subdivision Name CSM Number <br /> ElPublic/Commercial—Describe Use a - // u� <br /> 11 State Owned—Describe Use ❑City_❑Village 29Towuship of 94G/U.ON <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> `4' New System ❑Replacement System ❑Treatment/Ho)ding Tank Replacement Only ❑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.Type of POWTS System: Check all that apply) <br /> (Non—Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑ Mound<24 in,of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Dri Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dia ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Arca Proposed(sf) System Elevation <br /> 306 • 7 1 112y 113a f3.2 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Turks Tanks <br /> Septic or Holding Tank 8� UO <br /> Aerobic Treatment Unit O <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/MPRS Number Business Phone Number <br /> 6?,?-ka 19100kI zzs�s i �rs86�- yis� <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 27;' ciwed LJi- sy <br /> .Countv/Deipartiiient Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date lssucd Issuin Signam Stamps) <br /> Surcharge Fee) /y <br /> ❑Owner Given Reason for DenialC �� '27 6� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> IL11L�ER <br /> I <br /> I <br /> Attach complete pint(to the County only)for the system on paper not leas than s inches iWV 2 r. / <br /> r <br /> BURNETT COUNTY <br /> SBD-6398 (R. 01/03) ZONING <br />