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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7082 , - <br /> isConsin Madison,W 153707-7082 Site Address <br /> Department of Commerce a77 &Awerz Dq�pvt94.. <br /> lication Sanitary Permit Numer <br /> Sanitary Permit A CIJ \l <br /> In accord rcith Conun 83.21-.Wis.Adm.Code,peel information you provide <br /> mac be used ter secondapurposes Privacy Law,sI5.04(1)(m) ❑ Check if Re%ision v <br /> '1 <br /> I. Application Information-Please Print All Information State Plan I.D.Number t� <br /> Property Owner's Name Parcel Number y) <br /> �G�jNrYI �fLOu1 tt1 <br /> 67-4-3130-63 <br /> Property Owner's Mailing Address Property Location <br /> .2sa77 Bep cal �aAd- SE '/4 SE '/:S 30 T 3R N R I q AfU) <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> Subdivision Name CSM Number <br /> II.Type of Building(Check all that apply.) ❑City <br /> 2r 1 or 2 Family Dwelling-Number of Bedrooms ]mss 3049 ❑Village <br /> ❑ Public/Commercial-Describe Use gTownshi <br /> ❑State Onned Nearest Roa <br /> 111.Type of Permit: (Check only one box on line A. Numbering is for internal use.) (Complete line B,if applicable.) <br /> .9. 10 NOs 3❑Replacement of 6❑Addition to <br /> System 2*eplacement System Tank Only Existing System <br /> For County use <br /> B' CCheck if Sanitan-Permit Previously Issued Permit Number Date Issued <br /> I <br /> IV,Type of POWT System: (Check all that apply. Numbering is for internal use.) <br /> 44 Xon-Pressurized In-Ground 21 ❑Mound 47 ❑ Sand Filter 50❑Constructed Wetland <br /> 22 ❑Pressurized In-Ground 41❑Holding Tank 48❑Single Pass 51❑Dnp Line <br /> 45 []At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpol Dispersal Arca Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> .1300 142 f 5V.?S. r/ . 7 o rP h '?/. 'f c/j/ Al <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> eptic r Holding Tank X00 POO oSK/4u) - <br /> Dosing Chamber <br /> VI Responsibility Statement- 1,then rsi ed,assume esponsibility for installation of the POWTS shown on the attached plans. <br /> Nonni(Print) I lumb Signature MP Number Business Phone Number <br /> i&K SEPTIC & EXCAVATI as'fp7� <br /> W1 54801 . <br /> - - — <br /> V IL County a artmen se Only <br /> Disappntved llate Issued Issui Agent Signan(rc iNo~(amps( <br /> Samtary Permit Fee(includes Groundwater <br /> :Aphn,ced �U��ner Given Initial Adverse Stucharge Fee) -aj-06 - <br /> lleterrrtinatiun <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RECEIVED <br /> Attach complete plana(to the county only)for the system on paper not less than 91/2 z 11 inches in sire <br /> 2002 <br /> BURNETT COUNTY <br /> wi. ZONING oop' <br />