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Ranitary Permit Alrplieatiorr Safety& Buildings DkIals <br /> In accord with Confit 53.21. Wis, Adnt. Code 201 W. WashingtnVar <br /> See res erre side for instruclionc for completing this application PO fan <br /> injulb <br /> � SCQ�15��1 i'ersonal information)of provide nlm he used for sccondmv Purposes t dadimn. WI 5170 <br /> iW <br /> Department of Commerce II'ri�acv La«. s. 15.Od(I)(m)I (Snbnlil cmnpleted linm to count)'' <br /> slate of <br /> Attach conn tete plans(to the count) cop) oil])) Ibr e s stem,on paper no ess than 8-12 x I I inches in size. <br /> County BurnettState Sanitary P r nit t�ih r I1 refk if I . irn� reg' us ap icatirnt Stale Plan I.U Number <br /> 41A- 111104— <br /> ( F f- <br /> 1. Application Information- Please Print all Information Location: <br /> Property Owner Name 51I roper INWSE"" <br /> 514 S- <br /> Arthur H Steffen 2 1/4 1/4,519 00 ,N, j, d LW <br /> Property Owner's Mailing Address Litt Number 13tock Nnmher <br /> 601 3rd Ave na na <br /> City.Slate Zip Code Phnnc Numhcr Subdivision Name or CSM Number <br /> Osceola WI 54020 ( 715 )294-3267 na <br /> 11 Type of Building: (check one) U city <br /> U Village <br /> ❑ 1 or 2 Family Dwelling-No. of Iledrooms _450 _ <br /> M dosvu of Oakland <br /> O Public/Commercial(describe <br /> ❑ State-owned - — <br /> III Type of Permit: (Check only one box on line A. Check box on line 13 if applicable) Nrnrest Read <br /> Lake Ave <br /> A) 1. CYNew System 2. O Replacement 1 ❑ Replacement of 4 U Addition to 1'nrcel fns Numher(s) <br /> I Sstern dank Only Existin S 'stem 020 - 4319 - 02 300 <br /> 0) Pcnnit Nnmher Uale Issued <br /> O A SanitatX Permit was reviousl issued <br /> IV.'lFype of POWT System: (Check all thaf apple) <br /> I3Non-pressurized In-ground O Notmd ❑ Sand Filter U Constructed Wetland <br /> 17 Pressurized In-ground U Holding lank U Single Pass U Drip Linc <br /> ❑At-grade O Aerobic Iteatment Unit Cl Recirculating f7 ( thcr: <br /> V Dispersallfrealment Area Information: __ __ <br /> 1.Design Flow(gpd) 2.DispersJRrea 3 Dispersal Arca 4 Soil Application 5 Percolatitnl Rate 6 System Filcvafion Z Final Grade <br /> Required Propnsed Rate((;nls./dny/sq. R.) Win/inch) Elevation <br /> 450 375 377 .7/1.2 na 96.00 98.90 <br /> VI Tank Capacity in l otal of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Uallons _ Gallons Tanks Com- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks — -- — <br /> 0 U U O Ll <br /> Se t"C 1000 -- 1000 1 Wieser <br /> — --- — - - -- U Ll U ❑ <br /> VII Responsibility Statement <br /> 1 the undersigned,assume res onsibility for installation of the I'M I S shown on the attached <br /> Plumber's Name(print) fflh+wc"4'1Z',' 0AA_ <br /> nature in s1,111199 MI'/MFRS No. Business one Number <br /> Donald Daniels MP 330/221593 1 715-349-5533 <br /> Plumber's Address(Street,Cif}'.State.7.ip Cnd0 <br /> PO Box 316 <br /> Siren WI 54872 <br /> V111 Coll nty/Uepnrtmen t Use Only _ <br /> Disaproved Sanitary I'ernnt�ce(In /G rd«�fcr D ucd <br /> QDetetmilatict <br /> Kpproved OwneGien Initial Adverse Surcharge feF)(yV G/ �IX. Conditions of Approval/Reasons for Disapprmal! � <br /> MqY 8 � <br /> S vI� /0-70 5- C�! 0�a� Zo"j"G /vT Y <br />