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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 /> `VaseonsinSee reverse side for instructions for completing this application PO Box 7302 <br /> Department or Commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> Attach complete lans to the coup co only)for the tem on of less than S-I/2 x 11 inches in size. state owned <br /> County �n State Ssni Permit Number ❑ if 'aion previo application State Plan I.D.Number <br /> u t<rll C 2 <br /> I.A lication Information-Please Print all Information ,� <br /> Properly Owner Name Location: <br /> I G d Q Property Location <br /> Property Owner's Mailing Address �Zd(/45644 S/ 17b N R <br /> Lot Number Block Numbe <br /> 17 City,State Zip Code Phone Number <br /> Subdivision Name or CSM Number <br /> s• �S a I l (6 - 19a cv' t 4s Vt V <br /> II.Yypie of Building: (check one) ❑city <br /> 1 or 2 Family Dwelling-No,of Bedrooms; ;L ❑Village <br /> Public/Commercial(describe use): FTown of + )� <br /> ❑ State-Owned J GC{�7f1 t <br /> III.Type of Permit: (Check only one box on— <br /> line A. Check box on line B if applicable) Ne Road <br /> A) I. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(ss) <br /> B <br /> System Tan Only ExistingSystem Q/�- —per '700 <br /> Permit Number Date Issued <br /> 13A SanitaryPermit was Previouslyissued <br /> IV.Type of PO WT 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- ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V.Dispernsalfrreatimnent Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Ares 3.Dispersal Arca 4.Soil Apphration 5.Percolation Rate 6.3yetem Elevation 7.Final Grade <br /> Required Proposed Rate(Gals day/sq.R) (Mindinch) <br /> cZOO Elevation <br /> J 7 '7 <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 /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> the undersi ed assume res na[bili for installation of the POWTS shown on the attached plans. <br /> Plumber's Name ) Plu s SigtuWrc( s ); MP/MPRS No. Ph <br /> "'I note <br /> Number <br /> urs ��s aa� is X66 <br /> lum�Addresa(3l <br /> �ity,S te,Zip Code) � Q� <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date fesued Issuing rgoatrr o ) <br /> Approved ❑Owner Given Initial Adverse Surcharge F«) _ <br /> Determination v( s <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br /> I � <br /> 14AY , 2W5 <br /> BURNETT COUNTY <br /> ZONING <br />