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4;w.co <br /> Sanitary Permit Application Sak, 3!7j <br /> Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 20ton Ave. <br /> See reverse side for instructions for completing this application ox 7302 <br /> iseonsin Personal information you provide may be used for seconds M07-7302 <br /> Department of Commerce ( rivacy Law,s. 15.04(I)(m)] n'purposes (Submit completmy if not <br /> ed. <br /> Attach com tete plans to the county copy only)for the system,on paper not less than 8-1/2 x I I inches in size. <br /> County State Sanit Pe it Number ❑Checkif revisi n to previous application State Plan I.D-14ber <br /> I.A ication Information-Please Print all n orirtation09 <br /> Location: <br /> Property Owner Name Property Location <br /> /f0 <br /> 1/4 1/4 S 371TA.N,)U E or W <br /> Propetty Owner's Mailing Address Lot Number Block Number <br /> — <br /> ,090/5 i,JkF26 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> kms 5Via. tx. l�sS <br /> II.Type of uilding: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 2 ❑Village <br /> ❑ Public/Commercial(describe use): ;Crown of 1 <br /> ❑ State-Owned 0fj/Z/. MO <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearpt R07 n oa t <br /> A) 1. ❑New System 2. _X Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) / <br /> S stem Tank Onl Existin S stem Q <br /> B) Permit Number Date ssued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground ❑Mound ❑ Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Requiredn Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> �oT <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> 32 �" 33. 2 2 $kAc✓ �' ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's N��aatmm�e(print) Plumber's Signature(no stamps): MP/MPRS No. r Business Phone Number <br /> r/acI/ <br /> umber's Address(Street,City State,Zip Co e) <br /> 2-3760 -3,<- <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date I ued Issuing t Si 5 <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) iTl 2 <br /> Determination <br /> I%. Conditions of Approval/Reasons for Disapproval: <br /> r <br /> SBD-6398 R07100 MA <br /> BURNETT COUNTY <br /> ZONING <br />