Laserfiche WebLink
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 <br /> Personal information you provide may be used for secondary purposes 5Box 7302 <br /> SCO/fSiin Madison,WI153707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper notless than 8-1/2 x 11 inches in size. <br /> Cougly" State Sanitary Permit <br /> e Number ❑ k if revi ionh vinous ap ication State Plan I.D.Number <br /> I.Ae tj <br /> pplication Information-Please Print all Information oC O� Location: <br /> Prope Owner Name / Property Location 7 <br /> 1$f-/ / S C ,/ 4 e r- W 1/4 SCl/4,S / T�B;N,RI E(or)C <br /> Property Owner's Mailing AddressLot Number Block Number <br /> \ <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> s;1-e.J A rr I.s—yf ;7 ( ) <br /> II.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑Public/Commercial(describe use):_ 41 Town of <br /> ❑State-Owned b '+N 2/S <br /> Ne are Road <br /> A- wi� l O�wSU <br /> Pare T Numbe s) o �Q v <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> n-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.Dispersal/Treatment 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 /> Required Proposed Rate(GalsJday/sq.ft.) (Min./inch) Elevation <br /> VII.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 /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Nament) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> �j hale- 7.f 4�)otvZ 2 6/- 211 7Y7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 09 6 X .S' III-'e Ys'7 2 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued _ i�u o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) �� <br /> Determination <br /> onditions of Approval/Reasons for Disapproval: aS�P <br /> A 2403 <br /> BURNETT COUNTY <br /> SBD-6398(R.07/00) <br />