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MA, Safety and Buildings Division County <br /> M <br /> 201 W.Washington Ave.,P.O.Box 7162 i k A N f <br /> scorec n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 t,1 59 O 7 <br /> Sanitary Permit Application State PlanI.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Cade,personal information you provide /o/ (e50 I '\ <br /> may be used for secondary purposes Privacy Law.sl5.04(lxm) Project Address(f different than mailing address) l/ <br /> L Application Information-Please Print All Information <br /> /1873 Hwy qB <br /> Owner's/Name � Lq I--�Ll) Parcel# Lot# Block# <br /> ft4Ed �C•'v-i/, f7le- 0'35V" /SZ/-(f/ (o0D <br /> Property Owners Mailing Address hope"Location / <br /> /5'6 3 0;?80 ` QL1 Gov E r w t 1-7 <br /> City,State Zip Code PhoneNmder K Section <br /> �N/8�37 Y71-zG3a circkone) <br /> Tr37 N: R —EorW <br /> 11 Type of Building(check all that apply) <br /> / <br /> 1 or 2 Family Dwelling-Number of Bedrooms ! ` /.sd q Subdivision Name CSM Number <br /> i <br /> Public/Conuoercial-Describe Use <br /> State Owned-Describe Use City_ Village Township of ra tr <br /> III.Type of Permit: (Cb on line A Complete litre B ff applicable) <br /> A New System Replacement System Treatment/Holdi <br /> rig Tank Replacement Only Oficr Modification to Existing System <br /> B• Permit Renewal Permit RevisionPermit Transfer to New List Previous Permit Number and Date Issued <br /> Change of <br /> Before Expiration Plumber Owiier <br /> IV. a of PONM System: <br /> Non-Pressurized In-Ground round ZTit in of suitable so Mound<24 in.of suitable soil At-Grade Single Pass Sand Filter <br /> Constructed Wetland Pressurized in-Ground Holding Tank Peat Filter Aerobic Treatment Unit Recirculating Sand Filter <br /> R Synthetic Media Filter Leaching Chamber Drip Line Gravel-less Pipe Other(explain) <br /> V.DispersaVIreatment Area Information: <br /> Design Plow(gpd) Design Soil Application Rak(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Ddevation <br /> /SD /, a /,ro /SD /Da. r?$ <br /> VL Tank Info Capacity in Total I Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units concrete Constructed Glass <br /> New Esisting <br /> Tanks ar Tacks / <br /> Holding Tank 7iSe f q!r� x <br /> Aerobic Trentareat Unit <br /> SOA <br /> tRespiattsibility Statement-I,the undersigned,assmne blhty for of the POWTS shown on the attached ans.s Name t) Number <br /> 4t /Q„r,�-ti� ZZZ87z- Y7Z— zyzl <br /> Ws Address(Street City,State,Zip ) <br /> a26 U ,/e kee k GL/, t.7-Veps3 <br /> VIII.Corin /De artment Use OiJ, <br /> APP Disapproved laniary Permit Fee(includes Groundwater Date Issued <br /> Sarebarge Fee) 300 3 0� <br /> Owner Given Reason for Denial <br /> DL Conditions of Approval/Reasons for Disapproval AUG - 4 <br /> 2 It <br /> BURNETT COUNTY <br /> ZONING <br /> Attach complete plans(to the County only)for the system as paper not less ala x 11 inches in size <br /> VVn 1<'20Q rD n1 MIX <br />