Laserfiche WebLink
kc <br /> Sanitary Permit Application Safety&Buildings D t n <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washingto <br /> See reverse side for instructions for completing this application PO B <br /> `�seonsin Personal information you provide may be used for secondary purposes Madison, to oun - 2 <br /> Department of Commerce (Submit completed form to coun t <br /> [Privacy Law,s. 15.04(l)(m)] <br /> state o d. <br /> Attach complete plans to the county copy only)f9rthe system,on paperjiot less than 8-1/2 x I 1 inches in size. <br /> County State Sani[ Permit Number heck i Vis onto to revio application State Plan 1.D.Number <br /> a <br /> 1.A ication Information-Please Print all Information Location: <br /> Property Owner Name Property Location nQn <br /> fl Wj- <br /> �l/4 <br /> l/4,S `1T tN or <br /> Property Owner's Mailing Address f Lot Number Block Number <br /> D <br /> City,State Zip Code Phone Number ber <br /> RkIwAv lb 54530 5b- 356 ;Z0 *Xv; <br /> II.Type o Building: (check one) ❑City <br /> ❑ 1 or 2 Family Dwelling-No.of Bedn m l ❑Village <br /> Public/Commercial(describe use): _ Z.�t �lE'179IL own of f�wlfs <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) 1. �[eW System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbe ) <br /> System Tank Only Existing System Z coo <br /> B) Permit Number Date Issued <br /> 11A 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 Molding 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 /> Requl'rgd Proposed Rate(Gals✓day/sq.ft.) (Min./inch) Elevation <br /> 113 AI <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> Amxw4- `61 / 71�gi✓ ❑ ❑ ❑ ❑ <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(no stamps): MP/MPRS No. Business Phone Number <br /> tAAW ApAel,4,15 ?25851 S - /S7 <br /> umber's Address(Street,City State,Zip Co e) <br /> 2..7760 3.S W150 TEM l,Jl. 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date 1 sued issuing.Agent Sign rare s mps) <br /> pproved ❑Owner Given Initial Adverse Surcharge F /01 If <br /> Determination — s <br /> IX.Conditions of Approval/Reasons for Disapproval- / 1 �r <br /> k4al(A-60 ofa r�f2a ZVler r W`Ye�rr©1� YP C)� ��'��i�s. S/ 5� fcf Yore <br /> l <br /> 6W Al-CIL�Yt�4 S, �tl Wt) cL Yeetr'te+f a t/,eeis' TD 1)16/4 ,l��e0' � � y� /5'o <br /> SBD-6398 R07/00 f j' , T / <br /> 140v 2 xuuI <br /> BURNETT COUNTY <br /> ZONING <br />