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• <br /> • F-td-42.dotx(New 7/16) <br /> 41( Wisconsin Department of Agriculture, Trade and Consumer Protection <br /> ),,, Division of Food and Recreational Safety, PO Box 8911, Madison, WI 53708-8911 <br /> ti- Phone: (608)224-4720 Fax(608)224-4710 <br /> CAMPGROUND PLAN APPROVAL APPLICATION Wis.Admin. Code ch.ATCP 79 <br /> Complete all sections. For sections not applicable,indicate with"N/A".Type or Print Only. <br /> Application is for: ®New Campground El Modification/Additions(briefly describe): <br /> CAMPGROUND NAME COUNTY PHONE: <br /> Burnett County Forest Keizer&Banach Lake Campsites Burnett (715)349-2157 <br /> CAMPGROUND ADDRESS STREET CITY STATE ZIP <br /> 5299 Bushey Rd Webster WI 54893 <br /> LEGAL LICENSEE NAME(Name of sole proprietor,partnership,LLC,LLP,or Inc.) EMAIL ADDRESS PHONE: <br /> Burnett County Forest& Parks susan.tollander@burnettcountywi.gov (715)349-2157 <br /> LICENSEE ADDRESS STREET CITY STATE ZIP <br /> 8150 State Rd 70 Siren WI 54872 <br /> NAME OF AGENT FOR THE CORPORATION/OPERATOR(if applicable) INTENDED DATE OF OPENING FOR BUSINESS <br /> Susan Tollander 10/19/23 <br /> PREVIOUS BUSINESS NAME PREVIOUS OPERATOR NAME <br /> Please check all boxes that apply,and enter the number of systems that are existing or will be new: <br /> WATER SUPPLY Existing: ❑Municipal ❑Private Well(s) New: ❑Municipal 0 Private Well(s) <br /> WASTEWATER SYSTEM Existing: ❑ Municipal ❑Private Sewer/POWTS' New: ❑ Municipal ❑Private Sewer/POWTS' <br /> SANITARY DUMP STATION Existing: ❑Municipal 0 Private Sewer/POWTS` New: ❑Municipal 0 Private Sewer/POWTS' <br /> ATCP 79,Wisconsin Administrative Code,for petition for waiver requirements for Sanitary Dump Station <br /> `Private Onsite Wastewater Treatment System <br /> LIST TYPES OF CAMPING UNITS INTENDED FOR CAMPSITES(Tents.RVs,etc.)and toilet numbers: <br /> CAMPSITE INFORMATION Example Existing New <br /> Sites and Provisions" p (Currently licensed) New site(s) <br /> (All sites not designated will be used to calculate toilet fixture needs) TOTAL&SITES NUMBERS TOTAL&SITES NUMBERS <br /> List types of camping units for campsites(tents,RVs,etc.)by site Tents:1-10,21-29 <br /> numbers RV's:30-40 ' -2 rho /' <br /> (Provide range where appropriate) 11-20 <br /> Total number of campsites 40 <br /> caa <br /> Total sites and site numbers with water and sewer connections 11/30-40 <br /> Total sites and site numbers with water connection only 9/Y1-Y9 <br /> Total sites and site numbers with sewer connection only 10/11-20 <br /> Total sites and site numbers without sewer or water 10/1-10 J/-09- <br /> Identify by site numbers the total sites designated for <br /> Independent camping units(see definition below) 21/30-40, <br /> (Identify by "I" on Plan Drawing) 11-20 <br /> Identify by site numbers the total sites designated for 19/1-10, <br /> dependent camping units(see definition below) 21.29 /, <br /> (Identify by "D" on Plan Drawing <br /> Identify by site numbers the total number of sites designated for use by <br /> both"I"and"D'"camping units.(Identify by"B"on Plan Drawing) <br /> TOILET FACILITIES(Number of units) Site No.used:(a)-(b) Existing New <br /> Female: Flush toilets 2 <br /> Privies(vault or pit) 1 <br /> Showers 2 <br /> Hand sinks 2 Variance approved 11/1/23 for toilets at <br /> Male: Flush toilets 1 rustic campsites. <br /> Flush urinals 1 <br /> Vault urinals 0 <br /> Privies(vault or pit) 1 <br /> Showers 2 <br /> Hand sinks 2 <br /> "Independent camping unit"means a camping unit,which contains,at a minimum,a water storage facility and a toilet facility,which discharges to a <br /> liquid waste holding tank that is an integral part of the unit or to a sewage disposal system. <br /> "Dependent camping unit"means a camping unit without a toilet and which therefore depends on campground toilets. <br />