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Sanitary Permit Application Safety&Buildingsi n <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W,Washing e <br /> PO 2 <br /> C. <br /> See reverse side for instructions for completing this application B <br /> ��sconsin personal information you provide may be used for secondary purposes Madison,WI 537MISM2 <br /> Department of Commerce (Submit completed t o <br /> [Privacy Law,s. 15.04(1)(m)] ( leted form to coup f <br /> p <br /> state o e <br /> Attach complete plans to the county co only)forthe system,on a of less than 8-1/2 x 11 inches in size. <br /> County State S i ary P 't umber ❑ ek if r v'sion to previous pplication State Plan I.D.Number <br /> 02 Z <br /> 111f n <br /> I.AppTication Information lease Print all Information i, Location: <br /> Property Owner Dame Property Location r�// {{�/ <br /> 1/4 1/4,S4S N,RIDE or W <br /> Property Owner's Mail' Address /- ,'Y1 Lot Number Block Number <br /> 110 6LQJW ltvloe V? <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> oom 1wrJ s'3I Q K V go ip. lq3 <br /> I .Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling- of Bedrooms: 3Village <br /> ❑ gown of <br /> Public/Commercial(describe <br /> use): h�{J7V <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Roa <br /> A) 1. 'Y New.System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel's Numb 4 <br /> System T7�n <br /> ExistingSystem 1!/�/N ap <br /> B) umber Date Issued <br /> ❑A SanitaryPermit was previouslyissued <br /> 1V.Type of POWT System: (Check all that apply) <br /> Non-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.QSystem Elevation 7.Final Grade <br /> Required Prop sed Rate(Gals./day/sq.ft.) (Min./inch) �I Z-G EI vatio <br /> ro (9+3 �4g t <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> D4'> (000 1 Sl ❑ ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/MPRS No. Business Phone Number <br /> umber's Address(Street,City State,Zip code) <br /> 2.7760 3S W105rl WI- S4Sg3 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groutt4water Date yssue [ssuin gent Si mps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee ©� (sy-6 //� <br /> Determination I j// <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> RECEIVED <br /> SBD-6398 R07/00 <br /> (MAY 3 2002 <br /> BURNETT COUNTY <br />