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Safety and Buildings Division County <br /> NN <br /> m 201 W.Washington Ave.,P.O.Box 7162 �Ur <br /> �scons�n Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 't--3 312--, <br /> Sanitary Permit Application State Plan I.D.Number j <br /> In accord with Contra 83.2 1,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s 15.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Property Orvuer's Name // Parcel# Lot# Block# <br /> o6(o2,/3 <br /> Property Owner's Mailing Address Property Location '00 <br /> Z 2 O /d , ��/<, Section <br /> City,State Zip Code Phone Number <br /> ,r�.circle one) <br /> T�N; R / Eo® <br /> II.Type of Building(check all that apply) <br /> I or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use /� <br /> ❑State Owned-Describe Use ❑City_❑Village Township of �tn,'@ Z <br /> 1II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System y � Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing 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.Type of POWTS System: (Check all that apply) <br /> NNon-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Weiland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter A Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Oilier(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sI) System Elevation <br /> lyse) , 7 Gy2gG X00 2 93,x/- P,? <br /> VI.Tank Info Capacity in Tolal Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank <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 Signaw <br /> FrZ-Rmb�S NuBus Hess Phone Number <br /> Robert Carlson Jw5 (715)653-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII.Court /Department Use Only <br /> Approved L1 Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Iss ent Signa o Stamps) <br /> Surcharge Fee) r , <br /> 11 (honer Given Reason for Dmial z9'T'uy U3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> JUL 2 .9- 2W <br /> BURNETT COUNTY <br /> Attach complete plans(to the Cormty only)for the system on paper not less than 81/2 a 11inches in siu <br /> cRT)_Azosz to AI/nz� <br />