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IaretyamtlwlnuipDivision <br /> isconsin 201 W.Washington Ave.,P.O.Boz 7162 r yr e <br /> Madison,WI 53707-7162 Site Address <br /> __Department of Commerce <br /> Sanitary Permit Application sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm. Code,personal information you provide ,/� 7 <br /> may be used for seen ses Priv Law,s15. C111 m) Check if Revision �f <br /> I. Application Information-Please Print All Information Sate Plan 1.1). Number <br /> Property Owner's Name <br /> Parcel Number <br /> -4Je rr tau /as vii,- 1160 -D3 - 310 <br /> Property Owner's Malting Address ,[/ n ® Property Location L (�� <br /> �.7S'3 ( J.& f-Crr-eS /t Gr It ti St✓ ,q:S lS T �t0 N.R i1� E <br /> Ewe�s�_er- <br /> Zi codeP Phone Number Lot Numbez Block Number <br /> bdivision Name CSM Number <br /> Wr- SS� 973G csm 366s" v. tiff 10 <br /> ,10 7 <br /> II.Type of Building(check all that apply) <br /> Q 1 or 2 Family Dwelling-Number of Bedrooms 3 ❑City <br /> ❑ Public/Commercial-Describe Use ❑Village <br /> ❑Sate Owned Wownship O&C,/C s&^ <br /> Nearest Road <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) <br /> A. I ® New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to Far County use <br /> SY <br /> sum Tank Only Existing System <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized ht-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment 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.) (Min./Inch) I Elevation <br /> Lj <br /> Llro <br /> VI.Tank Info Capacity in Total Number I Manufacturer I Prefab Site Steer I Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed I Glass <br /> New Existing j . <br /> Tanks Tanks ! <br /> Septic or Holding Tank X ! j <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 Pbone Number <br /> 15 S66- 4J722S$S - <br /> Plumber's Address(Street,City,Sate,Zip od ) <br /> Z77 (oo /4wy �S UI�BST1Z 1,11 . �400 jS <br /> ! VIII. County/De artment Use Only- <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwarar Date Issued IssuLgg Aget �n re No S .ps! <br /> Surcharge Fee) <br /> ❑ Owner Given[nidal Adverse <br /> .2, <br /> - Determination X 16-0 � <br /> LY. Conditions of Approval/Reasons for Disapproval -- <br /> RECEIVED <br /> i'V 7 2003 <br /> A.'tach complete plans(to the Count)only)for the syrtem on paper not less than 81;2.1 11 inches in size <br /> SBD-6398 (R. 05101) BURNETT COUNTY,' <br /> ZONING ow- <br />