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Sanitary Permit Application Safety&Buildings Divi <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Av <br /> �seonsin See verse side for instructions for completing this application PO Box 7 <br /> Nepartment oT Commerce Person information you provide may be used for secondary purposes Madison,WI 53707-73(\ <br /> [Privacy Law,s. 15.04(i)(m)] (Submit completed form to county i <br /> Attach complete lens o the coon onl for th s stern,on a t less than 8-1/2 x 11 inches in size. state owe <br /> CO1mn State San P it u ❑C ifsio�t to v' application State Plan . Number <br /> !�r✓�c dd <br /> I.Application Information-Please P t Information Location: <br /> Pro er Name <br /> ProPorty Location <br /> Property�h J ng-Xd y✓��/� S 'l/4 1 1/4 S�T <br /> O er's Mailing Address -?7,N,R or <br /> Lot Number Block Number <br /> a2 S 33 /.3e=a ver <br /> City,StateZip Code Phone Number <br /> Subdivision Name or CSM Number <br /> I.Type of Building: (check one) nn ❑Cin, <br /> 1 or 2 Family Dwelling-No.of Bedrooms r X ❑Village <br /> ❑ Public/Com nercial(describe use): to ffown of <br /> ❑ State-Owned _ <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) N t Road <br /> railer A* /t�. <br /> JB) <br /> 1. ew System 2. ❑Replace ent 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> 5 stem Tank Onl Existin S stem <br /> Oa 313,0 -e'l,a - 7" <br /> Permit Number Date Issued <br /> ❑A SanitaryPermit was reviousl iss ed <br /> IV,TYpe of POWT System:(Check all that apply) <br /> O'Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other. <br /> V.DispersaYrreatment Area Informatin: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3. i Wp sal Area 4.Soil A lication 5.Percolation Rate 6.5 <br /> Re uired PP ystem Elevation 7.Final Grade <br /> 4 P Rate(GalsJdaylsq.tl.) (MinJinch) / Elevation <br /> 3e)® ��9 �a 9 - 7 r/7, 23 <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 /> ,.,C[ Tanks Tanks <br /> SP /J c 7 lJ 7-rO ❑ ❑ ❑ ❑ <br /> / l'a/ el/„i <br /> VII.Responsibility Statement <br /> I the undersigned,assume res ibility for installation of the POWTS shown on the attached plans. <br /> �Plumbers Name(print) �Plurnbees Signature(no stamps): MPj%TR�SINo. / Business Phone Number <br /> VYCil1Q L r:. �.QeaJo-� OW)— <br /> PluUmber's Address(Street,City,State,Zip`Code) <br /> /YC aJ fc<' <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit (Includes Groundwater Date Issuing g Si <br /> Approved ❑Owner Given Initial Adve Surcharge F« ^ <br /> Determination UJ <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> URE ;. <br /> SBD-6398 R07/00 <br /> JUL 5 2002 <br /> BURNETT COUNTY <br /> ZONING ,d- <br />