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0().Ob G,/ae� <br /> Sanitary Permit Application Safety&Buildings Division <br /> SIn accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> isconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce Submit completed form to <br /> [Privacy Law,s. 15.04(1)(m)] ( P county if not <br /> state owned. <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State San' Pe Number ck i revisio top vious application State Plan 1.D.Number <br /> I.Application Information-Please Print all Information J Location: <br /> Property Owner Name Property Location nn� <br /> Sl_I EfZ 1/4 1/4 S2! T <br /> ProperTy Owner's Mailing Address Lot Number <br /> V,o2p W. SAV• S.E. l0 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> ?9 10P, L.14 MPJ• S53 2 L1e 441- 351D 6415 LAY-96u;6 looseg <br /> II.Type of Building: (check one) ❑City <br /> 0 I or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> Public/Commercial(describe use): Town of <br /> ❑ State-Owned uA101 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road /� �� 1 Lk Ply.r YQPk) J• <br /> A) I. 4New System 2. Replacement 3. ❑Replacement of 4. ❑Addition to Parcel T 1ju <br /> S stem Tank Onl Existin S stem 03(9— 6a 7r-02. <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> Type of POT System: (Check all that apply) <br /> IX.-Type <br /> 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.S stem Elevation 7.Final Grade <br /> Re u'red Proposed Rate(Gals./day/sq.ft.) (Min./inch) I}•1 Elevation g6.1 <br /> OA3 �4B ,1 --- 4.6 g6.10 <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 /> [ <br /> � �, <br /> Tanks Tanks <br /> L 'a 1000 ❑ ❑ ❑ ❑ <br /> PC (000 600 ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature o ps): MP/MPRSSNo. Business Phone Number <br /> Number's Address(Street,City,State,Zip <br /> CCo e) ��QQ y� ' 1 <br /> 2-2 -760 HW-4 .3-5W5WQ W) <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater rDatctlssued Issuing Agent Signature(No stamps) <br /> 11Approved ❑Owner Given Initial Adverse Surcharge Fee) r, <br /> Determination U <br /> IX.Conditions of Approval/Reasons for Disapproval: <br /> S13D-6398 R07/00 <br /> BURNETT COUNTY <br /> ZONING <br />