Laserfiche WebLink
Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21. Wis. Adm. Code 201 W. Washington Ave. <br /> Visconsh1 See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison. WI 53707-7302 <br /> Department of Commerce (Privacy Law.s. 15.04(I)(m)] (Submit completed form to county if not <br /> state owned. <br /> Attach complete plans(to the count) copy only)for the system,on paper not less than 8-1/2 x 1 I inches in size. <br /> County State Sanitary Permit Number OIQh ck if rfpisionto preus application State Plan 1.D.Number <br /> Burnett xF 679789 a <br /> 1. Application Information - Please Print all Information Location: ° <br /> Property Owner Name Property Location I� <br /> Don Bollinger <br /> I/a I/a,S 35 T 39 N,ek8fq'( r w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 2206 St Anthony Ave 4 na <br /> City,Slate r55104 <br /> Code Phone Number Subdivision Name or CSM Number <br /> St Paul NN ( 651-6?9-4893 CSM Vol 15 Pg 56 & 57 <br /> 11 Type of Building: (check one) ❑City <br /> NY 1 or 2 Family Dwelling—No.of Bedrooms: 3 O Village <br /> ❑ Public/Commercial(describe use): _ 23CTown of Meenon <br /> ❑ State-owned <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> Clam Shell Ln <br /> A) I. M New System 2. ❑Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> System Tank Onl Existing System 018 — 3335 — 02 202 <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-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑Other: <br /> V Dis ersaVTreatment Area Information: <br /> I.Design Flow(gpd) 2. DispersalAren 3 Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.0.) (Min./inch) Elevation <br /> 400 na na na na na na <br /> VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> holding tank 2000 -- 2000 1 Wieser Concrete <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> I,the undersigned,assume res on ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) PI tber's Signature(no stamps) jTMP/MFRS No. Business Phone Number <br /> Donald Daniels 330/221593 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 316 Siren WI 54872 <br /> VIII County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Is t Agent Si lure(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination `$0 no to-a6 o <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> i <br /> OCT 2 5 zuu1 <br /> BURNETT COUNTY <br /> ZONING <br />