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Safety and Butldmgs UIV151nn FLounty201 W.Washington Ave.,P.O.Box 7162wiseonsin Madison,WI 53707-7162 Address <br /> Department of Commerce <br /> Sanitary Permit Number <br /> Sanitary Permit Application <br /> in accord with Comm 83.21.Wis.Adm.Code,personal information you provide ❑ Check if Revision 4-V 0.2— <br /> may <br /> Zma be used for secondary Purposes Privacy Law,s15. 1)(m <br /> I. Application Information-Please Print All Inform 'on State Plan I.D.Number <br /> Parcel Number S <br /> Property Owner's Nam//Y! ��� e n1-I U'`l�30--01- Sp <br /> o <br /> Property Owner's Mailing Address Sb' Property Location /.3 e��— <br /> 4 erX ?d/ AJ t< Solt;S 5 T YO N.R 48 E <br /> City,State Zip Code Phone Number Lot Number Black Number <br /> Subdivision Name CSM Numbe <br /> II.Type of Building(dheck all that apply) ❑City _ <br /> K—or 2 Family Dwelling-Number of Bedrooms ❑village _ <br /> ❑Public/Commercial-Describe Use ®Township 6j, <br /> ❑State Owned Nearest RoadN®/w A,t !/� l"L 77.T K <br /> III.Type of Permit: (Check only one box online A(numbering scheme for.internal use). Complete line B if applicable)) <br /> A For County use <br /> 1 ❑ New 2 placement System 3 ❑ Replacement of 6 ❑ Addition to <br /> System Tank Ord Existio S stem <br /> B. ❑ Check if Sanitary Permit Previously Issued <br /> Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44 XIon-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wedand <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 3o❑Other <br /> V.Dis ersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Race System Elevation Final Grade <br /> Required Proposed Rate(Gals./DayslSq.Ft.) (Min./Inch) Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Concrete ConSite tucted Sieel Fiber PL• itic <br /> Gallons Gallons of Tanks <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tarek O490 <br /> Dosing Cumber <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plsms.� <br /> Plumber's Name(P int) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> 61 � 4/ s - <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIII. County/Department Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issuing Ag tare v ps) <br /> Approved ❑ Disapproved Surcharge Fee) <br /> ❑ Owner Given Initial Adverse 25 J 02 <br /> Determination r L� <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> NOV 2 .9 2M L <br /> BURNETT COUN <br /> Attach complete plans(to the County only)for the system on paper not less than$111 s 11 inches in size ZONING <br /> SBD-6398 (R. 05/01) <br />