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Safety and buildings Division t:aunly <br /> ` 201 W. Washington Ave., P.O. Box 7162 13arne7l` <br /> isconsin Madison, WI 53707-7162 Site Address <br /> Department of Commerce 1 d_rA <br /> Sanitary Permit Application Sanitary PermitN�umber JJ //' lI <br /> q <br /> In accord with Comm 83.21.Wis.Adm.Code,personal information you provide `'99-1-/7 ` (lyJ <br /> w be used for secondpurposes Privac Law, .O4"(1)� (m 11 Check if Revisions 1111 <br /> I. Application Information-Please Print All Information TI State Plan I.D. Number f <br /> Property Owner's Name U Parcel Number v 1 <br /> Carl 1?-,eke Na- <br /> Property Owner's Mailing Address Property Location <br /> 7377 rnAa Sk' u JE ll:S J 1 T yO N. R IS <br /> City,State Zip Code Plane Number Lot Number Bicck Number <br /> Subdivision Name CSM Numix <br /> we5ste W.t' .x'4833 a t 8(06- 85dt0 <br /> II.Type of Building(check all that apply) ❑city <br /> o I or 2 Family Dwelling-Number of Bedrooms <br /> ❑Village _ <br /> ❑Public/Commercial-Describe Use Or7ownship /^e-ese" <br /> ❑State Owned Nearest Road <br /> Ce �c0 <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicabIL-) <br /> A. I Rt New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System I Tank Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Dale Issued <br /> IV..Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 is Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Diu ersaVTreatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (.Mln.flnch) Elevation <br /> �fSD 643 90d . 7 — 14•� 9S:& <br /> VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Seel Fiber Ph die <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> 0 <br /> Septic or Holding Tank /00 <br /> Dosing Chamber <br /> V U. Responsibility Statement- 1, the undersigned,assume responsibility for installation of the POWTS shown on the attached pl:,os. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Pborr.Number <br /> tick �/o /Elms /�i�s a�/� adSBS/ 7i.S-9'6e, c1/.S7 <br /> Plumber's Addres (Street,City.State,Zip Code) <br /> 77(00 yk. 3S websfr f✓� S�i893 <br /> . Count /De artment Use Only <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agem cure(No ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse �i, 5O� ii �'� - .1 <br /> Determination ,�i <br /> IX. Conditions of ApprovaVReasons for Disapproval ` <br /> AUG ; 2005 U <br /> BURNETT COUNTY <br /> Attach complete plans(to the County only)your the system on paper not lesa than ST/r-%" 'Al in sire <br /> SBD-6398 (R. 05/01) <br />