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ON COMPUTERISCANNED <br /> Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 V <br /> iseonsin Madison,Wl 53707-I 10L Smitary Permit N (to be filled in by Co.) <br /> De artlnent of Commerce (608)2663i5t � �Q 13 <br /> Sanitary Permit Application Sante Plan LD.Number <br /> In accord with Comm 8321.Wis.Adm.Code.personal information you provide j 76,1 <br /> may be used for sccondary purposes Privacy IoW.315.04(I)(m) Project Address(if different than mailing address) <br /> L Application Information-Please Print An Information <br /> Property Owner's Name Parcel# Lot# Block# <br /> :TM 5Tej Kj o1 - 7672 - -loo + a( o <br /> Property Owners Mailing Address Property Locaboo <br /> City,State Ti(p+C�o+de Phone Number �p�. St, Section <34 <br /> I V dC)O 1- 1062 T G�! N. R.&71E3 r ) <br /> IL Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> lor2Family DweUung-NtumberofBgdrooms I � n^� <br /> PublidLCommcrcial-Describe Usemr W/��)j. <br /> State Owned-Describe Use City_ Village Township of/�ICh j6N <br /> IIL Type of Permit: (Checlk only one box on line A. Complete line B if applicable) <br /> A" New System Replacement System TresmtimtlHolding Tank Replacement Only Other Modification to Existing System <br /> B. Permit Renewal Permit RevisionChange of Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWIS System: (Check all that apply) <br /> Non-Presramed In-Ground Motmd:�24 in.of suitable soil Mound<24 in.of suitable soil At-Grade Single Pass Sand Enter <br /> Constructed Wetland Pressurized In-Ground 6oiditg Tank Peat Filter Aerobic Treatment Unit Recirculating Sand Filter <br /> Recirculating Synthetic Media Filter Leaching Chamber Drip.Line Gravel-less Pipe Other( - ) - <br /> V.Dispersalfrreatment Area Information: <br /> Design How QVd) Design Sod Application Rase(gpdst) Dispersal Area Regaiccd(st) .Dispersal Area Proposed(st) System Elevation <br /> VL Tank Info Capacity in Total Number Mmmfactmer Prefab Site Steel Fiber Plastic <br /> Gallons. Gallons of Units Concrete Constructed Glass <br /> New Psistiag <br /> Tanks Talcs I <br /> Sep6ca Hoking Tank <br /> W r <br /> Aerobic Tramtmt Unit - <br /> Dosing Mamba . <br /> VII Responsibility Statement-1,the undersigned,assumme responoety for" of the POWTS shown on the attached plans. « <br /> P1t®bees'Name(Print) I Plambe's S amber Business Photo Number <br /> ZrFrF 7G Q z3ziZ 715-ZQQ-314 <br /> Plumber's Address(Street,City.State,Zip ) <br /> P.b. �t3-0 x 2c S SE2 / Sq pB <br /> VIIL co c Use Only <br /> Approved �m,,e Sanimry Permit Pee(includeserromdwater Date tsated �{ Lqsm <br /> sarchazgo Fee) <br /> 4 2n/so <br /> Owner Gives Reason for Denial .�L.(./ (J <br /> IIf.Conditions of Approval/Reasons for Disapproval <br /> OCT 1 5 M <br /> r <br /> BURNETT COUNTY <br /> Attach complete plan(to des County only)ear the system an paper awl tea than all2 x ll inches in sin <br />