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Safety and Buildings Division County <br /> ` 201 W.Washington Ave.,P.O.Box 7162 !Barn P� <br /> Wisconsin Madison,WI 53707-7162 SanitaWermit Number(to be filled in by Co.) <br /> Depe of Commerce (608)266-3151 '1 9 A *1 D <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(I)(m) Project Address(if different than m`[ail... <br /> L address) —� <br /> Application Information Print All Information q el/3-7 C'O / n /'r 9 <br /> i_711 <br /> Property Owner's Name // Parcel# Lot# Block# <br /> Dove //at�MtiM OAP ;'109 O/BOO <br /> Property Owner's Mailing Address Property Location 6a/Al. COT' <br /> `1Y3o Gla��l , rl Sr L 9 <br /> City,State Zip Code Phone Number —Y., —hA Section <br /> Shoreview Irl nJ SS/} 6 y0 (circle one) <br /> II.Type of Building(check all that apply) T_N; R 1e E Q& <br /> AIor2Family Dwelling-Number ofBedrooms y Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑village RITownship of -5*C-&- <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> New System El Replacement System ❑Treatment/Holding Tank Replacement Only ❑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 /> IV.Type of POWTS System: Check all that apply) <br /> 5rNon-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Welland ❑ 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 ersa/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 gs8 85�! 9s r, �s <br /> VI.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 mHolding Tank _S-O .S/Ca rr <br /> Aerobic Treatment Unit <br /> Dosing Chamber <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 /> RIC/c 1-7-1, &I. 5 /2cc �/� a1,1,S-6S/ 7/f e66- v/s> <br /> Plumber's Address(Street,City,State,Zip Code) <br /> t)[ 77/O / r 3-i;— Gt/ebs�`ri WSSef893 <br /> VIII.County/Department Use Ord <br /> (Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing nt ..gna tamps) <br /> Surcharge Fee) � �� .�✓ // <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> CI' <br /> 1 <br /> Attach complete plant(to the County only)for the system 6 2006m on paper not le a than 11 inches in size <br /> BURNETT COUNTY <br /> SBD-6398 (R. 01/03) ZONING <br />