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' Sanitary Permit Application91 <br /> In accord with Comm 83.2 1,Wis.Adm. Code Safety&Buildings st <br /> iseonsin See reverse side for instructions for completing this application 201 W WashO e. <br /> Department of Commerce Personal information you provide may be used for secondary purposes Madison,WI B <br /> [Privacy Law,s. 15.04(I)(m)] (Submit completed forrn to coun <br /> Attach com fete lans to the coun co on )for the s stem,on a state t <br /> County a of less than 8-1/2 x I l inches in size. ) <br /> State San'ary P r�t u her <br /> ❑ eck if revision to previous plication State Plan t.D.Number <br /> I.A icaIlion Information-Please Print all Info anon <br /> Property Owner Name Location: <br /> tv J,4F <br /> (Property ALocation <br /> Property ex Mat ling Address VV� 1/4lvC 1/4,S T ,N d e W <br /> O V Lot Number Block Number <br /> City,State Zip Code <br /> L4 <br /> / M_ / 55 <br /> Phone Number Subdivision Name or CSM Number <br /> II.Type of Building: (check one) ) V• Z- &I- <br /> 0 1 or 2 Family Dwelling-No.of Bedrooms: ❑City <br /> ❑ Public/Commercial(describe use): Village <br /> ❑ State-Owned Town of SWIss <br /> III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road <br /> A) (• 13 New System 2. Replaccment 3. ❑Replacement of 4. ❑Addition to Parcel Tax Numbers) 26 <br /> B System Tank Onl <br /> Existing System 071 571M o2 Zoa <br /> ❑A Sanita Permit was reviously issued Permit Number <br /> IV,Type of POWT S stem: Check all that apply) <br /> Date Issued <br /> System: ( <br /> on-pressurized In-ground <br /> ❑Pressurized In-ground ❑ Mound ❑ Sand Filter <br /> 11At- ade El ° <br /> Holding Tank ❑Constructed Wetland <br /> ❑Aerobic Treatment Unit Single Pass ❑Drip Line <br /> V.Dis ersal/Treatment Area Information: ❑ Recirculatin ❑Other: <br /> I.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area <br /> 4•Soil Application 5.Percolation Rate 6 <br /> / Required Proposed .System Elevation 7.Final Grade <br /> Rate(Gals./day/sq.ft.) (Min./inch) y <br /> 3 Elevation <br /> VI.Tank J �� �j9 6 � • � <br /> Capacity in Total r of Manufacturer <br /> Information Gallons Gallons Tanks Prefab Site Steel Fiber- Plastic <br /> New Existing Con- Con- glass <br /> Tanks Tanks I lee structed <br /> VII.Responsibility Statement <br /> ° ❑ ❑ ❑ ❑ <br /> I,the undersi ned,assume res onsibillity for installation of the POWTS shown on the attached plans <br /> Plumber's Name(print) Plumber's Signature(no stam s <br /> P ) MP/MPRs No. <br /> Qt-� Business Phone Number <br /> umbers Address(Street,City State,Zip Co e) v�"`5, s: _ P <br /> 2770.0 02 151 In1�85TEK loll. S48G3 <br /> VIII,County/Department Use Only <br /> ❑Disapproved Sanitary Permiee(Includes G ndwater <br /> FKpproved :1 Owner Given Initial Adverse Surcharge Fee)I{ Date jssue Issuin A ent Si <br /> Determination `���a /'�// a� stam s) <br /> IX. Conditions of Approval/Reasons for Disapproval: v Y✓� (p <br /> SBD-6 �E I <br /> 398 807/00 <br /> JUN 5 2002 <br /> BURNETT COUNTY.; <br /> --� ZONING 1,..' <br />