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Sanitary Permit Application Safety& Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave, <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> ` iseonsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> oeoartment or commerce (Privacy Law,s. 15.04(I)(m)] (Submit completed form to county if not <br /> _ state owned. <br /> Attach complete plarts to the county copy only)for the system,on paper not less than 8-1/2 x l I inches in size. <br /> Count to Sanitary Permit Number ❑C13eck if revision to previous application State Plan L D.Number <br /> �c ryl.e c �s :s <br /> 1. Application Information- Please Print all Information Location: <br /> Propeny Owner Name //'� P, /roperty Location <br /> T 1,.e `'G n Yt S W I/4/ hd4 S N./-�(,r W <br /> Property O nods Mailing Address Lat Numb�j Bock Number <br /> tagl�c yf 3 T G�l''�t� <br /> Gty,State Zip Code Phone Number Solid is�°r CS�+�Number - - <br /> iYeroe� 7n dslllr_ <br /> 11. Type of Building: (check one) ❑city <br /> 1 or 2 Family Dwelling-No. of Bedrooms 3 ❑Village <br /> Public/Commercial(describe use): Q Town of <br /> ❑ State-Owned <br /> 111. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearj(Rpaep'�S C k <br /> A) 1 ❑ New System 2 !$I Replacement 3. ❑ Replacement of 4. ❑Addition to Parcel Tax NN{umbeer(-ss))� f�0 <br /> ;y' <br /> Tank Onl Existin_P System Q —, C� <br /> B) Permit Number Date Issued <br /> ❑ A Sariaary Permit was previously issued <br /> IV. Type of POWT System: (Check all that apply) <br /> ArNon-pressurized in-ground ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ❑ Pressurized In-ground O Holding Tank ❑Single Pass ❑Drip Line <br /> ❑ At-gTade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V. Dispersal/Treatment Area Information: <br /> I Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.n.) (Min./inch) Elevation <br /> q�0 3� S � 8 l . z �7�{ s I <br /> V1. Tank Capacity in Total q of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks- Tanks <br /> � 1C <br /> 1600 <br /> t Po$-Qf❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 1 <br /> i <br /> Vll. Responsibility Statement <br /> 1,the undersigned,assume res onsibil for installation of the POWTS shown on the attached plans. <br /> Plumbcfs Name rint PI tuber's Signatur (no ps): MP/MPRS No. Business Phone Number <br /> e(, I KV Z2. Z2- 7tS <br /> Plum'oer's Address(Street,Ci y,Stale, ip Code) <br /> 7 Co c v Est UR -Le ��r <br /> Vlll. County/Department Use Only <br /> ❑ Disapproved Sanitary Pe it Fee(Includes Groundwater Date Issurr}}11 Issuing g i Sign re( ps) <br /> pproved ❑Owner Given Initial Adverse Surcharge <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 ROV00 <br /> J v//r <br /> 1'r lam] � v I <br /> / I <br /> NOV _ 5 1UU1 <br /> BURNETT COUNTY <br /> ZONING <br />