Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Bur n <br /> Nvisconsin <br /> Madison,WI 53707-7162 Sanitary�'Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 <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,sI 5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information <br /> Overlaa'eP IQGf• <br /> Property Owner's Name Parcel# Lot# 1A Block# <br /> Jinl Al�lsa� Ora.- 115-00—a�aloo <br /> Property Owner's Mailing Address Property Location <br /> PI ,13 <br /> /°, '/., Section <br /> City,State Zip Code Phone Number <br /> /rry, /e woo/ /V 41 s-Sy/q 6V- 7Z-9977 (circle ) <br /> II.Type of Building(check all that apply) T ye) N; R Ir E of <br /> Z 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name (/_J.�� CSM Number <br /> L1 Public/Commercial-Describe Use I-ayI tv c / <br /> 1 V.V r <br /> El State Owned-Describe Use []City—[]Village Township of,,7Gt G lt.10Il <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> BList Previous Permit Number and Date Issued <br /> ❑ Permit Renewal ❑ Permit Revision ❑ Change of El Permit Transfer to New <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> R 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 34 1 • 7 4/,9 yid 93.9 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New FExisting <br /> Tanks I Tanks <br /> Septic or Holding Tank 800 9 0 0 1 skA w <br /> Aerobic Treatment Unit 6 <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,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 /> Ie-k ffq/Cin S 0+1�5—:rs- 7/S- X66- 4/S7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> A776 0 1/w r 3s' W-ehsie✓ W.1- -5"gVF3 <br /> VII our /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuin Signatu Stamps) <br /> Surcharge Fee) <br /> ❑ Owner Given Reason for Denial W /� <br /> IX.Conditions of Approval/Reasons for Disapproval r� <br /> io rUlu <br /> BURNETT COUNTY <br /> ZONING <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in site <br /> SBD-6398 (R. 01/03) <br />