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Safety and Buildings Division County <br /> NVisconsin <br /> 201 W.Washington Ave.,P.O.Box 7162 t.t r✓1e Madison,W1 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce <br /> (608)266-3151 (o B /d fo <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sI5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information Tr <br /> Property Owner's Name Parcel# Lot# Block# <br /> O1;, 'Mo oJ. �1oO <br /> Property Owner's Mailing Address Property Location <br /> Q it <br /> City,StateZip Code Phone Number SIA' V•. Section <br /> .5 74 G✓OirC Fa�/S Wy'- 5", <br /> DV L/ 7/S- r/03— /301 g circle one) <br /> y0 R / <br /> II.Type of Building(check all that apply) T N; E otS) <br /> A 1 or 2 Family Dwelling-Number of Bedrooms <br /> 3 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use t <br /> ❑State Owned-Describe Use ❑Cit_❑VillageKTownship of J^z k_fCYi <br /> III.Type of Permit: (Check only one box on fine A. Complete line B if applicable) <br /> '4' X New System y ❑Treatment(Holding Tank Replacement Only ❑Other Modification to Existing System <br /> y ❑ Replacement System <br /> B• ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV-.T of POWTS System: Check all that apply) <br /> ,bNon-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> �lSd r 900 900 9s,o/ 11..4 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks <br /> Septic or Holding Talc <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> ?Ick /t/e krn s Ria«-aP s�r� sir-��d- v1s7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> aX 776 o C/r .y <br /> 11. <br /> I .Coun /De artment Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Date Wued IssumiiA <br /> Sedt Signature mps) <br /> Surcharge Fee) <br /> ❑Owner ti ven Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D V� <br /> NOV 1 Z 2004 <br /> Attach complete plans(to the County only)for the system on paper not leas tban 81B hes In size <br /> BURNETT COUNTY <br /> SBD-6398 (R. 01/03) ZONING <br />