Laserfiche WebLink
LIACZYW <br /> Safety&B ildings Division <br /> Sanitary Permit Application 201 W.Washington Ave. <br /> In accord with Comm 83.2 1,Wis.Adm. Code PO Box 7302 <br /> See reverse side for instructions for completing this application Madison,WI 53707-7302 <br /> seons�n Personal information you provide may be used for secondary purposes (Submit completed form to county if not <br /> Department of commerce (Privacy Law,s. 15.04(I)(m)J state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x I I inches in size. <br /> County State S Lary 1'emtit Numb 9 . ❑Check if�ision to previous application State Plan 1.D.Number <br /> 3 g d(001 <br /> Location: <br /> 1. Application Information- Please Print all In Property Location , <br /> Property Owner Name <br /> r' � � Lot�Number I/4,S T Block umber <br /> Pr rty neer's Mill Addrelss /� <br /> �J�7 Fes+ / 7� /�v• — qd /�-.�� r <br /> Code <br /> Phone Number 9abd+vieionn Akrxe or CSM Number <br /> City,State Lill <br /> �t/rG F5' /o (6S ) 7 -97 Z <br /> ❑City <br /> 11.Type of Buil ing: (check one) ❑Village <br /> PI or 2 Family Dwelling-No.of Bedrooms: -/Bd S.� 0 Town of <br /> ❑Public/Commercial(describe rise):_ Cry <br /> 6B� <br /> ❑State-Owned Nearest Road <br /> 11111"Ill I--SrDEe.r:s�v�Rs I III <br /> cl <br /> rF <br /> Ill.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 5 6. ❑Addition to <br /> A) 1 New 2. ❑ Replacement 3. ❑aRk Replacement of 4. Existing System <br /> ystem System permit Number Date Issued <br /> B) <br /> ❑A Sanitary Permit was previously issued <br /> 1V.Type of POWT System: (Check all that apply) ❑ Mound ❑Sand Filter ❑Constructed Wetland- <br /> Non-pressurized In-ground ❑ Sin 1CPa89• ❑ Drip Line <br /> 9 Pressurized In-ground ❑ I lording Tank g <br /> ❑ Aerobic Treatment l Init ❑Recirculating ❑Other: <br /> ❑At-grade <br /> V.DispersaUTreatment Arca Information: Final <br /> 1.Design Flow(gpd) 2. Dispersal Area a.Dispersal Arca 4.Soil Application 5.Percolation Rale ( y�tem�®/ti� Elevation rade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Cr7V�� <br /> y p 37� 'O - 7 r-a lok 0 <br /> VI1.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Gallons Gallons 'Tanks Con- Con- glass <br /> Information —New Pzisting crete strutted <br /> Tanks Tanks ❑ ❑ ❑ ❑ <br /> — <br /> VIII. Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the P (5 shown on the <br /> eS Nattached plans. Business I Number <br /> Plumbers N7 <br /> ame(print) Plumber's Signature(nn slam ): <br /> rltD o6'� T t � 2 / d - s"- 60� <br /> Plumbers Address(Street,City.State,7.ip Code <br /> cE�c/-Gsl- Yo2 <br /> Z'I C 6N z: '�C <br /> IX.County/Department Use Only <br /> ❑ Disapproved <br /> Sanitary I'cr i Pee(Includes Groundwater Date Issued ' Issuing Agent Sig btu (No <br /> prov d ❑Owner Given Initial Adverse <br /> Surcharge Fe <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: f <br /> r <br /> 9hCAV She uJ IY►l7f i'�> MAY - 2001 <br /> r 1`t(�PI BURNETT COUNTY <br /> LCZONING <br />