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Safety and Buildings Division county <br /> 201 W.Washington Ave.,P.O.Box 7162 &Awa <br /> IM�consin OF <br /> Madison,Wl 53707-1162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)2663151 2 <br /> Sanitary Permit Application smote Plan I.D. umber <br /> In accord with Comm 83.21.Wis.Adm-Code.personal information you provide 6& 76 <br /> tr ( (� <br /> may be used for secondary purposes Privacy Law,A 5.040)(m) Project Address(f different than mailing address) U <br /> L Application Information-Please Print All Information <br /> property owner's Name o` Parcel# J Lot# Block# <br /> Zlt Nx 5To m n► 672l <br /> Property owners Mailing Address Properly Location Qn 1 C <br /> u 'k Sectio <br /> Cl <br /> City.Stam Zip Code Phone Number <br /> � oh(IV� �p : j2 <br /> IL Type of Building(check all that apply) Subdivision Name CSM Number <br /> I or 2 Family Dwelling-Number of Bedrooms L/ W <br /> OcT (2^wou <br /> PubBdu <br /> Cawncial-Describe UseAar .n��. <br /> Stam owned-Describe Use Gly_ Village Township of/V ICf��6/V <br /> Type of Permit: (Check ori one boz on line A. Complete line B if applicable) <br /> A. New System Rpt System Treatment/Holding Tank<Replacement Only Other Modification m FAstmg System <br /> B. Permit Renewal Permit Revision Change of mit Transfer to New List Previous Permit Number and Date Ismed <br /> Before Expiration Plumber TG= <br /> IV.Type of POWTS System- (Check all that apply) <br /> Non-Pressurized In-Ground Mound L 24 in.of suitable soil Mound<24 in.of suitable soil At-Grade Single Pass Sand Filter <br /> constructed Wetland Pressurized In-Ground Holding Tack Peat Filter Aerobic Treatment Unit Recirculating Sand Filter <br /> Recirculating Synthetic Media Filter Leaching Chamber Drip Line Gravel4ess Pipe Other(explain) <br /> V.Dispersalffreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ram(gpdst) Dispersal Area Required(d) .Dispersal Area Proposed(sf) System Elevation r - <br /> VL Tame Info capacity in Total Number Manufacturer Prefab Site Steil Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tants Tanks <br /> Septic or holding Tank «� 3ooe� Logs k <br /> IVC <br /> Aerobic Treatment Unit - - <br /> Dosing ciamber <br /> VII nsfbflity Statement-I,the undersigned,assume respgosibillty for' of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) s umber Business Phone Number <br /> FF 9KS17 Z3Z`tZ 7/5-ZQQ-314 <br /> Plumber's Address(Strut.City.State.Zip <br /> VIII.Cour artment Use Only <br /> IV,Approved Disappror� Sanitary Permit Fee(includes Groundwater DaaQW lumiag Si o stamps) <br /> S) <br /> Given Reason for Denial Sarchazgc ) <br /> Fee <br /> OD 6 T - <br /> IX.Conditions of ApprovalMeasons for Disapproval L 1 <br /> OCT 1 s 2004 <br /> BURNETT COUNTY <br /> ZONING <br /> Attach complete plans(to the County ody)for the system on paper not less mon g12 x 11 inches in size <br />