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( --_'. y. <br /> Safety&Buildings ton <br /> Sanitary Permit Application 201 W.Washi 1 ye• <br /> • In accord with Comm 83.21,Wis.Adm. Code p0, 302 <br /> See reverse side for instructions for completing this application Madison,WI 53Q(t302 <br /> Viseonsin Personal information you provide may be used for secondary purposes (Submit completed form to couM 11knot <br /> ❑,epartment of commerce (Privacy Law,s. 15.04(1)(m)] stat d. <br /> The conn co onl )for the s stem,on a er not less than 8-1/2 x 11 inches in size. <br /> Attach com ete tans to t <br /> plication Stale Plan I.D.Number <br /> County <br /> State anitary Permit Number ❑Check i revision to previous ap <br /> Location: <br /> 1.A ieation Information-Please Print all Information Property Location /��JQ� 1 <br /> Property Owner Name 1/4 1/4,SaT `,N o W <br /> Lot Number Bloc Numb <br /> Prope wners Mai mg Address �� I /� S� /�YV <br /> (� <br /> �A J Y a O <br /> Phone Number Subdivision Name or C M Number <br /> City,State Zip Code <br /> W i . 548 o lS �s� <br /> ❑city <br /> II.Type of B ilding: (check one) E3 Village <br /> 1 or 2 Family Dwelling-No.of Bedrooms: own of <br /> ❑ Public/Commercial(describe use): <br /> ❑ State-OwnedNearest R ac) <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 3o /r <br /> n toP cel Tax Number(s) <br /> A) I. ❑New System 2. Replacement 3' T Tank OnlReplacy <br /> of 4. ❑stin`ttSystem 6 3a— <br /> $ stem Date Issued <br /> Petmit Number <br /> B) <br /> ❑A Sanita Permit was reviousl issued <br /> IV.Type of POWT System: (Check all that apply) ❑Mound ❑ Sand Filter C3 Constructed Wetland <br /> on-pressurized In-ground ❑Single Pass ❑Drip Line <br /> ❑Holding Tank ❑Other: <br /> ❑Pressurized In-ground ❑Aerobic Treatment Unit ❑Recirculatin <br /> ❑At- ade <br /> V.DIS ersal/Treatment Area Information: lication 5.Percolation Rate 6.System Elevation 7.Final rade <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area Rate(Galoil s./day/sq.fl.) (Min./inch) <br /> Required Propos d 0 /0/ 0 <br /> a ofManufacturer Pr�efa/b Site !St/eel Fi Plastic <br /> VI.Tank Capacity in Total Con- Con- glass <br /> I <br /> Information Gallons Gallons Tanks crete structed <br /> New Existing <br /> Tanks Tanks ❑ ❑ ❑ ❑ ❑ <br /> Z' OOD IovO ❑ ❑ ❑ ❑ <br /> el <br /> �DD <br /> VII.Responsibility Statement <br /> I,the undersi ned,assume res onsibility for installation of the Plumbers Signature POWTS shown on theS No.attached plans. Business Phone Number <br /> Plumbers Name(print) iture(no stamps): S$r! S' — / 7 <br /> umbers Address(Street,City State,Zip Co e) r�71 WI• 9400g3 <br /> 2.-7760 Xix4 3S W <br /> VIII.County/Department Use Only Issuing Agent ant ps) <br /> Disapproved <br /> ❑ Sanitary Permit Fee(Includes Groundwater Date Is ed � g g <br /> Afproved ❑Owner Given Initial Adverse Surcharge F ©� 7i/ 6 <br /> Determination l <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 BURNETT COUNTY <br /> ZONING <br />