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Safety and Buuc tags D[vnton Canmy <br /> ` 201 W. Washitaifton Ave., P.O.Boz 7162 v�Ar <br /> ►sconsin Madison,WI 53707-7162 Site Address ` <br /> Department of Commerce 8-ne1 li✓ Ln, <br /> Sanitary Permit Application Sawnry Permit Number (-f-- <br /> In accord with Cotrim 83.21.Wu.Adm.Code.personal information you provide Check if Re !,5 Q—'V 9,<T/ <br /> ma be used ffor secondary s Privy Law I5. I m v(slon <br /> I. Application Information-Please Print All Information Sita Plan LD.Number <br /> e <br /> Property owner's Name Parcel Number <br /> ftaly golkej <br /> Property Owner's Mailing Address Property Location <br /> L->016CA J u %:S 46 TtI N,R /7 <br /> City,State Zip Code P, on Number Lot Number Bkck Number <br /> Subdivision Name CSM Numb, <br /> 4 ti o/1/ y -6 a �i Aarl _ <br /> IL Type of Building(check all that apply) Ocity <br /> W1 or 2 Family Dwelling-Number of Bedrooms ❑village <br /> ❑Public/Commercial-Descra a Use — <br /> 911fV s —V <br /> ❑Slaw Owned Nearest rcu Rwd l/ <br /> r N �NG GN <br /> III.Type of Permit: (Cheek only one boa on line A(numbering scheme for.internal use). Complete Iine B H applkable) <br /> A. tut <br /> I W New 2 ❑ Replacement System 3 ❑ Replacemem of 6❑ Addition to For County use <br /> S rtem Task Existin Stam <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dao lswcd <br /> IV.Type of Permit: (Check all that apply)(numbering scheme Is for internal use) <br /> 44 (XNan-Pressurized In-Ground 210 Mound 47❑ Sand Filar 50❑ Constructed Wetland <br /> 22❑ Pressurised In-Ground 41 ❑ Holding Tank 48❑Single Pass SI❑Drip Line <br /> 45 0 At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Ram System Elevation Final Grade <br /> Required Proposed Rate(Gals.fDayslSq.F[J (Min.Mch) E(evarion <br /> 600 858 $ 58 9 y 5 975 <br /> VI.Tank Info Capacity in Total Number Mawfacwrcr PrcfaD giu S. Fiber P(n.aiC <br /> Gallon Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic <br /> Of Heking Tack /Z 5-0 <br /> Dewing Chunber I <br /> VII.Ru onsibil(ty Statement- I,the undersigned,assume responsibility for Installation of she POWTS shows on the attached pit=. <br /> Phu nbbeerr/mss Name(Prim) Plumber's Signature MP/MPPRSS Number Business Phon:Number <br /> Plumber's Address Street,City,Sita,Zip Code) <br /> w 3 w Li <br /> vul.Count /De artment Use only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date ISSUM Owing Signawrc(Nmei ps) <br /> Surcharge Fee) <br /> (]Owner Given Initial Adverse r <br /> Demmtination T ?�5 � rJt/JUt <br /> IX. Conditions of ApprovaVReuoos for Disapproval <br /> U I J� <br /> �I <br /> J <br /> Anxh mmplgr plane an We Cwary edy)rev the estate, Nper net Ina then alrr s II j" slu <br /> SBD-6398 (R. 05/01) BURNETT COUNTY <br /> ZONING <br />