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'aoa <br /> Sanitary Permit Application Safety&Buildings Dirftn <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washingto%ave. <br /> See reverse side for instructions for completing this application PO BdR"2 <br /> ®Vseonsin personal information you provide may be used for secondary purposes Madison,WI 5372 <br /> Department of Commerce [Privacy Law,s. 15.04(l)(m)] (Submit completed form to coup t <br /> statet'1'07l1lR. <br /> Attach complete plans to the county copy only)for Oe system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanit ermit�Jytnber ❑ eck if isiQq t prvi application State Plan t.D.Number <br /> I.A ication Information-Please Print all Information <br /> Location: <br /> Property Owner Name Property LocationkAT-qeNr /� <br /> g I/4 1/4,S'l T ,N, o <br /> Property Ownees Mailing Address Lot Number Block Number <br /> 02A R -S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Nu er <br /> 503 (>� 12- 7231 V. L- <br /> 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 I <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road a, <br /> l <br /> A) 1. XNew.System 2. ❑Replacement 13. ❑Replacement of 4. ❑ Addition to Parcel Tax N mber(s) 11mS stem Tank OnlyExistingSystem <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 ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑ Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At- de ❑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.fl.) (Min./inch) Elevation <br /> VI.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 /> Ge C, - %4*J ❑ ❑ ❑ ❑ <br /> S KEW ❑ ❑ ❑ ❑ ❑ <br /> Vill Resp nsibility Statement <br /> 1,the undersigned,assume res on ibility for installation of the POWTS shown on the attached plans. <br /> Plumbees Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> umber's Address(Street,City State,Zip Code) <br /> 277/0 3S W�ssr lull. S48G3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing a <br /> gent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> RECEIVED <br /> SBD-6398 R07/00 <br /> MAY 3 2002 � <br /> BURNETT COUNTY <br /> ZONING <br />