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Safety and Buildings DIVISIon -Oun <br /> AAW 201 W. Washington Ave.,P.O. Box 7162 <br /> I'Viseonsin Madison,WI 53707-7162 Site Address 104 <br /> Department of Commerce Sanitary Permit Number <br /> Sanitary Permit Application 445779 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide ❑ Check if Revision <br /> ma be used for secondary xs Privac Law,sty. 1Hm Stam Plan I.D.Number <br /> I. Application Information-Please Print All Information � n <br /> Uo� Parcel Number <br /> Property Owner's Name <br /> 43� <br /> Property Owner's Mailing/Address �(/ Property Location /� <br /> ,, 6 45 �i?. �/�N4' /�& ��Sf �'!i:S T%' N.R 6 <br /> City,State ,J Zip Code Phone Number Lot Nu ber Bieck Number <br /> v� Subdivision Name CSM Numbe <br /> /1A i��,�i ;2 4,5 a �3 <br /> II.Type of Building(check all that apply) ❑City — <br /> Vor 2 Family Dwelling-Number of Bedrooms � ❑Village <br /> ❑Public/Commercial-Describe Use ownship <br /> ❑State Owned Nearest R d <br /> III.Type of Permit: (Check only one box on line A(numbering scheme forinternal use). Complete line B if applicable) <br /> AFor County use <br /> i3O New E2D placement System 3 ❑ Replacement of 6 ❑ Addition toS stem Tank Onl Exi5 stemB. ❑ Check if Sermit Previously Issued <br /> Permit Number Dam 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 In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dga— <br /> ispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Ratc(Gals./Days/Sq.Ft.) (Min./Inch) �0 f) Elevari <br /> 3©o 14071,5? �,s� �� /oZ <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Si eel Fiber Pl: aic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic Holding Tank _ MA <br /> sing Chamber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the pOWTS shown on the attached pla os_�_ <br /> Plumber's Name(Print) Plu r Signature MP/MPRS Number Business Phon:Number <br /> 511i/�t f2 <br /> ;2.2 41177 715 $_ <br /> Plumber's Address(Street,City.State.Zip Code) �+jCt„�-71/ <br /> D / ® SLG /S 7 c' <br /> V-UL Count /De aliment Use Onlys) <br /> Id Approved 13 Disapproved Sanitary Permit Fee(includes Groundwater Date issued Iswin gena gna ( tat,p <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse 1 <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> MAY - 2004 <br /> BURNETT COUNTY <br /> Attach complete plans(to the County only)ror the system an paper nor less than 81/2 x 11 laches io sae <br /> SBD-6398 (R. 05/01) <br />