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Sanitary Permit Application Safety&Buildi ton <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Wash Ave. <br /> isconsin See reverse side for instructions for completing this application P 7302 <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI 7302 <br /> [Privacy Law,s. 15.04(1)(m)] (Submit completed form to cou not <br /> Attach complete tans to the coun co onl )for the s stem,on a er not less than 8-1/2 x l l inches in size. sta ed. <br /> DIpplication <br /> State i u ber k if rgpision to revious <br /> p o pplication State Plan 1.D.Number /IWN <br /> Information-Please Print all InformationLocation: �F�— <br /> wner Name <br /> Property Location <br /> Property Owner's Mailing Address I/4 I1/4, 6f`f7AA'' <br /> ,N,AE W <br /> Lot Number <br /> 0l�7Z01- �L• <br /> City,State Zip Code Phone Number <br /> Subdivision Name or CSM Number <br /> I�lIJ�1-onIKA Mtl- S 4S ) - `107 . 6 P. 0 <br /> 11.Type of Building: (check one) 0 City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): Town of <br /> ❑ State-Owned <br /> II1.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. ❑New System 2. (Replacement 3. ❑Replacement of 4. ❑Addition to Parcel rax Numbelr(� �� C/i�• <br /> S stem Tank Onl ExistingSystem (03C:2 <br /> 7�jissued <br /> B) Permit Number Date <br /> ❑A SanitaryPermit was previouslyissued <br /> IV.Type of POWT System: (Check all that apply) <br /> XNon-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑ Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculatin ❑Other: <br /> V.Dis ersal/Treatment Area Information: <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) <br /> 0 A i/ 45 j Elevation <br /> 'f- L. � .--- yea-- 9�•.f <br /> VI.Tank Capacity in Total t#of - Manufacturer Prefab Site Steel Fiber- Plastic t <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> 1000 I I NORInIE,ScO ❑ ❑ ❑ ❑ <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/MFRS No. <br /> Business Phone Number 3 <br /> umber's Address(Street,City State,Zip Code) <br /> 2-7760 'jS W156M Wl. 54893 <br /> VIII. County/Department Use Only <br /> LDetermination <br /> Disapproved Sanitary Pernit Fee(Includes Groundwater Date IssuedIssuingAgent Signaturpproved Owner Given Initial Adverse Surcharge Fee) nn /^�,`�f\ <br /> roved <br /> 00 612 <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> L <br /> �,'�ri�.,,�a►� <br /> ?('o-m D kJ N l &A-h L4,K 4 <br /> SBD-6398 8071100 <br /> BURNETT COUNTY <br /> ZONING <br />