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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 /> AsConsin See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce itd fttif(Submit completed o county no <br /> [Privacy Law,s. 15.04(1)(m)] Q� <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper nodless than 8-1/2 x 11 inches in size. <br /> County State Sanitary n9iNumber 11 Che revision toprevious a lication State Plan 1.D.Number <br /> Burnett *4 &4z1 <br /> I.Application Information-Please Print all Information Location: <br /> Property Owner Name Property Location GL 4 <br /> Laverne Hubbard 1/4 v4,s18 738 ,N,d5iE cr)w <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 23860 Malone Rd -- -- <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Siren WI 54872 ( 715 )349-5367 — <br /> II.Type of Building: (check one) ❑city <br /> W 1 or 2 Family Dwelling-No.of Bedrooms:�— ❑Village <br /> ❑Public/Commercial(describe use):_ 13 Town of LaFo l l ette <br /> ❑ State-Owned <br /> Nearest RoMalone Rd <br /> Parcel Tax Number(s014-2218-01 800 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. eplacement 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 /> EXNon-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.Syto le {�0 Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Cell y �`f. I 0J,7. <br /> Elevation <br /> 450 643 684 .7 na cell #2 93.701 95.64 <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- I <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> 1000 — 1000 1 Wieser Concrete ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) PI ber's Signature o stamps): MP/MPRS No. Business Phone Number <br /> Donald Daniels MP 330/221593 T715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 316 Siren WI 54872 <br /> IX.County/Department Use Only <br /> � ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing ent ' ature ps) <br /> [H"Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />