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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Visconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to coup <br /> [Privacy Law,s. 15.04(1)(m)] ( p ri if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on paricr not less than 8-1/2 x 11 inches in size. <br /> County State Sanitary Permit N tuber Check re�y)isi o revs us application State Plan I.D.Number <br /> Burnett p -4 cT <br /> I.Application Information-Please Print all Inf rmation Location: <br /> Property Owner Name Property Location <br /> Richard & Mary Hill G1 4 1/4 1/4,s 2 T40 ,N,R1W W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 7278 S Verbera Way 3 na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Englewood CO 80112 303-350-9683 na <br /> II.Type of Building: (check one) 13City <br /> 19 1 or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village <br /> ❑ Public/Commercial(describe use): §q Town of Oakland <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Neare Road <br /> Hayden Lake Rd'E <br /> A) 1. 5j New System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Pa c IT N b r(s) <br /> System Tank OnlyExistingSystem 0Y6 — 4gi <br /> B) Permit Number Date Issuyd <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System:(Check all that apply) <br /> M 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 ersaVrreatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> 300 Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 250 265 1.2 na 97.03 99.20 <br /> V1.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 /> S�PtI� 1000 -- 1000 1. Wieser comb KI ❑ ❑ ❑ ❑ <br /> 0"ftf 600 -- 600 1 Wieser comb ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume res onsibili or installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plu s Signatttre( stamps): MP/MPRS No. Business Phone Number <br /> Donald Daniels NIP 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 " Issuing gent Signature(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) ©� r7— <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br /> Go moon eat <br /> s80 ioIoS -Yo (Al. 0//0/) <br />