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Safety and Buildings Division County <br /> ` 201 W.Washington Ave.,P.O.Box 7162 it,r e <br /> �scons�n Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 'f R 5 )49D <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide __Vr- <br /> may be used for secondary purposes Privacy Law,sl 5.04(l Hm) Project Address(if different than mailing address) _ <br /> 1. Application Information-Please Print All Information D n�Qr 0" 7?�. <br /> Property Owner's Name Parcel# Lot# / Block# <br /> Jt-n C7efmar bld - 'iJay- 053 0 <br /> Property Owner's Mailing Address Property Location V �e (.07 <br /> eLl 7Xenwee® ..4✓Q � <br /> City,State Zip Code Phone Number �• —�• Section <br /> Se- Za K/1 /Dn✓k MAI X-5-e/1(7 3 (cirosIcle one) <br /> II.Type of Building(check all that apply) T qO N; X24 E <br /> Q 1 or 2 Family Dwelling-Number of Bedrooms <br /> a( Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use a <br /> P. <br /> 11 State Owned-Describe Use ❑City_❑Village ownshipof Jiackforl <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. El ��// <br /> New System /[1 Replacement System ❑Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> ImmVrr.Type of POWTS S stem: Check all that apply) <br /> .xa Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.D's ersal/freatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(at) System Elevation <br /> 300 s- (nap 6po 9yd a 93 > <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 7� 7Sp <br /> Amobic Treatment Unit <br /> Dosing Chamber 500 1 500 <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature/ MP/MPRS Number Business Phone Number <br /> Rfe-A tint �enw�e// e(/ SSS/ 7i� 966— S/S7 <br /> Plumber's Address Street,City,State,Zip Code) <br /> 77 e f/r 35- GrJBd s `ri GAS -!;J/L97 3 <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee mcludesundwater Date Issued Issuing ignature mps) <br /> Surcharge Fee) O^`J 'f //r,^//rwli r <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval q� - <br /> Attach complete lam to the Court only)for the system on <br /> P P ( Comity Y) Yr paper not lea Mae 81(2:11 inch i MAY <br /> SBD-6398 (R. 01/03) BURNETT COUNTY <br /> ZONING <br />