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Safety and Buildings Division County <br /> c 201 W_Washington Ave.,P.O.Boz 7162 U <br /> iscon. Madison WI 53707—7162 <br /> Department of Commerce (608)266-3151 Sa"'ta`yPermitNamber(�befilledinbyCo.) <br /> /'( <br /> r <br /> Sanitary Permit Application Smte Plan LD.Numi/ter <br /> 1n accord with Comm 8311.Wis.Adm.Code.Personal information you provide (JV <br /> maybe used for secondary Purposes Prm7(O <br /> ivacy taw,sl5."l)(m) Project Address(f ddfamt than mailing address) (� <br /> L Application Information—Please Print All Information a 5� T'Zo,Pc,0 " J <br /> Property Owner's Name aV <br /> �sb <br /> UI M Parcel# Lot# Black# <br /> Property Owners Mailing Address 01 �2 - b _i_ +70 <br /> G �)z Properry`oaaa'°°urtiTZ— (p, r7 <br /> City.State Tap Code Phone Number Section <S q <br /> Liji <br /> IL Type of Building(check all that apply) Q� r T v! N; R ffQ E of + ) <br /> I or 2 Family Dwelling-Number of Bedroom { Subdivision Name CSM Number <br /> PublidCommacial-Describe Use L T n ,n1� <br /> State Owned-Describe Use CIO V <br /> Gly- Village Township of/v�N6N <br /> IIL Type of Permit: (Che(it only one box on line A. Complete line B if applicable) <br /> A <br /> New System Replacement System TMRM=UHotdmg Tank Replacement only Other Modification to Existing System <br /> B. Permit Renewal Permit Revision <br /> Before Expiration Change of Permit Transfer to New Dist Previous Permit Number and Date Issued <br /> Plumber Owner <br /> IV.KyPeof POW15 S : (Check all that apply) <br /> Non-Pressurized In-Ground Moundk 24 in.of suitable soil Mowll<24 in,of suitable soil At-Grade <br /> Constructed Wetland Single Pass Sand Filter <br /> Pr�wrized f fix-Ground Holding Tack Peat Filter Aerobic Treatment Unit Recircv <br /> Remeadatuag Synthetic Media Filter P latmg Sand Filter <br /> I.. Ching Chamber Drip.Lice Gravel-less Pi Other(explain) <br /> V.D' rsameatment Area Information: <br /> Design How(gpd) Design Soil Application Rate(gpdsf) Dispesal Area Requited(sf) :Dispetsal area <br /> Proposed(sf) System Elevation <br /> VL Tank Info Capacity in Total Number � r <br /> Gallons. Gallons of Units Manufacturer Prefab Site Steel Fiber Plastic <br /> New Existing Concrete Constructed Glass <br /> Tanks Tanks •�, <br /> Sepdror Holding Tank - <br /> ArmbicTresttaeatUmt "`� •�� <br /> IJoatag(3amba - <br /> VII. fluty Statement-I,the aadersigmd,>ssome <br /> Plumbers Nates(P6u) Auks r bBily for, of the POYM. shown on the attached <br /> PF S& urd>K Busitea Phoue Number <br /> Plumbers Address(Street,City.State,Tip <br /> P.b. �t3n x 226 sE2 w/ syo� <br /> t Use Onl <br /> t/AWruved Disappmved > , F <br /> Fee(includes Groundwater Date issued Si o Stmtgn) <br /> Owns Given Reasam for Decrial � 7v. � /t] Qil, <br /> IX Conditions of Approval/Reasons for Disapproval 7/ 7 <br /> I� l <br /> U v ~J LI <br /> i <br /> OCT 1 5 204 <br /> BURNETT COUNTY <br /> Atti6 rnmplete P�(to the i-m ody)[or ere system oa paper net lass than rig x 11 inches io rlsn AIG <br />