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Sanitary Permit Application safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> Visconsin 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. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) � <br /> Attach complete plans(to the county copy only)for the system,on pape of less than 8-1/2 x 11 inches in size. <br /> Cou ty State Sanitary Permit Number ❑ heck if re inion to previous pplication State Plan 1.D.Number <br /> 43eb302, a 855,494 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> r r � ' .S GJ e "j-56 rJ 1/4 1/4,So? T A,R E(or) <br /> Property Owner's Mailing Address Lot Number Block N ber <br /> .;? ?7 Y07� ,e--1 y LQ,,u`- aT <br /> City,State// Zip Code [Phoi�c Number Subdirisiorrhfame or CSM Number <br /> y hire /,rJ� SYS ) 5Ieg,26137 V/O oe F' 7 <br /> II.Type of ilding: (check one) ❑City <br /> 0— 1 or 2 Family Dwelling-No.of Bedrooms. ❑Village <br /> ❑Public/Commercial(describe use):_ r— RYTown of L <br /> Cl State-Owned -rr14C"J'B ��Il e- <br /> Nearest Road Z as <br /> Parcel Tax Number( <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. IX.Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> 13) 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 ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground 5KIolding 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 /> VII.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 /> A,/ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <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's Signature(n tamps): MP/MPRS No. Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuin nt Sign o stamps) <br /> Approved 1 ❑Owner Given Initial Adverse Surcharge Fee) 1, <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> JUL 2 1 2003 <br /> BURNETFCOUNTY <br /> zaWING <br /> SBD-6398(R.07/00) <br />