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Safety and BuildinqDivisionCity <br /> LAI 201 W.Washington Aved in—i�► iseonsin Madison,Wl 537Sanitary Permit N (to be filled in by Co.) <br /> (608)266 3 , ,° 3 <br /> ent of Commerce vSanitary Permit ApplicationState Platt I.D.Number <br /> b.aaonrd with Comm 8321.Nris.Adm.Code.Persona(information YOU provide /W ?�/ <br /> may be used nor sc u. .y pu.po Privacy Law..15.04(1X.) Roject Address Cif dffe.0 ltl ml msmling addles.) <br /> L Apphadon IdW=99n-Plt ase Print A!!InfolTnation <br /> Property Owners Name Parcel 6 Lot# Block tl <br /> �Tl NX 5TC1 K T n - 1 -W + a <br /> Plopedy OWWeS Mailing�Ad2= P`°p"`' `°cadet (in <br /> i-Ls <br /> 1+ r� . <br /> Q t9W w, K Section 34 <br /> (City.State Tip Code Phone Number ,/ <br /> L.��Q �4 �" �p T�! N; RLl2�ot ) <br /> IL Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> 1or2FamilyDwelling-Number ofBedroom �T cmin1Vlnf <br /> PublidCommercial-Describe Use W�`�� A <br /> State Owned-Describe Use City_ Village Township of1 /U <br /> III Type of Permit (Check only one box on line A_ Complete lisle B if applicable) <br /> Fiv. <br /> New System Replacement System TreaimendHolding Tads Replacement Only Otber Modification to Existing System <br /> Permit Renewal Permit Revision Changeof Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owns <br /> T of POWTS S : (Check all that a I )on-Pressurized la-Ground Mound)24 is of suitable soil Mound<24 in_of suitable soil At-Grade single Pass Sand Filter <br /> Constructed Welland Pressurized la-Ground Holding Tadr Peat Flier Aerobic Treatment Unit RecirwWiog Sand Filter <br /> Recirculating Synthetic Media Filter Leaching Chamber Drip Lim Gmvd-kss Pipe Other(explain) <br /> V.DispersWrreatment Area Information: <br /> Design Flow QT d) Design Soil Application Rate(gpdsf) Dispersal Area RWaired(sf) .Dispersal Arra Proposed(sf) System Bevation r _ <br /> VL Tank Info Capacity in Total Numbs Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons: Gallons of Units Concrete Committed Glass <br /> [icw Existing <br /> Tans I Tanks ,s� r c <br /> sepuaaHol�mg Teak Z ZB00 (Nt6Ge] <br /> Arabic Treatment Unit <br /> losing G4ambe r <br /> VIL 'ty Statement-L the undersigned, ty formsbRab' of We PORTS shown on the attached plans <br /> Plumber's Name(Picot) Plombees S umber Business Phone Number <br /> FF r _Z32,92, ��5'ZQ4-314 <br /> Plumbees Address(Sheet City,State,zip ) <br /> 611 <br /> P.6. .3)5 x 2-45 s� I sUoe <br /> VUL Coun t Use Only <br /> Sanitary Permit pec Cmdudes2GmMandwaoer I Date Issued > <br /> Approved Disapproved Satcharge Fee) <br /> V Owner Given Reason for 1)eaiat <br /> DL Conditions of Approval/Reasons for Disapproval TjLEI <br /> OCT 1 5 20 <br /> BURNETT COUNTY <br /> Attach complete Plans(to the Comny adz)for the syafem oro WPer mrt las team X12 x 11 indh run size ' <br /> ...cry unauuc 1v�dl 111bVc4.:LU1 N. All Permits <br />