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Sanitary Permit Application <br /> In accord with Comm 83.2 1,Wis.Adm. Code Safety&Buildings Divisiot, <br /> isconsin See reverse side for instructions for completing this application 201 W Washington Ave. <br /> Department of Commerce Personal information you provide may be used for secondaryPO Box 7302 <br /> [Privacy Law,s. 15.04(1)(m)] proposes Madison, to 53707-7302 <br /> Attach tom tete lans to the coun co on] or the s stem,on a er not less than 8-1/2 x I l(suinches inmit psizea form to county n not <br /> County state owned. <br /> e Stale Sani Permit Number Ch y�k if revision to evious application State Plan I.. Number <br /> I.A lication Information-Please Print all nformat*0 9i—a y g5 <br /> Property Owner Name LOCatIOn: <br /> iJC E J eC k el- PropertY Location ` <br /> Property Owner's Mailing Address Sh/ 1/4 Atl✓ 1/4 S 30 J" <br /> G T 4/ ,N,Rl E or <br /> At it b r lI 141, Lot Number Block Number <br /> City,State Zip Code 1 V0/, /7 �4/0es'q; le j <br /> J 1"0 4 k-e f i7N 1 S`SQ Phone Number <br /> qSubdivision Name or CSM Number <br /> (check one) <br /> II.Type of Building: 65`l 7/7- 79'V, /S Aere5 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑City <br /> ❑ Public/Commercial(describe use): ❑Village <br /> ❑ State-Owned a Town of <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) NNearest Road <br /> A) I. New System 2. ❑Replacement 3. ❑Replacement of 4. 5 c/m a eu IPc� <br /> S stem ❑Addition to Parcel Tax Number(s) <br /> B) Tank Only Existin S stem fart e f — 03 -.Sfi3o- �t— *400 <br /> ❑A Sam Permit was reviousl issued Permit Number — e 31 - o -0 300 <br /> IV.Type of POWT System: (Check all that a 1 Date Issued <br /> M-Non-pressurized In-ground PP y) <br /> ❑Pressurized In-ground ❑Mound ❑Sand Filter <br /> 13At- de ❑Holding Tank 11 Constructed Wetland <br /> O Aerobic Treatment Unit ❑Single Pass ❑Drip Line <br /> V.Dis ersal/Treatment Area Information: ❑Recirculatin ❑Other: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area <br /> Required Proposed 4.Sod Application 5.Percolation Rate <br /> g5ev- Rate(Gals./day/sq.ft.) (Min./inch 6.System Elevation 7.Final Grade <br /> Gy3 06 �� 4PPe�es!/ 9 •1 Elevation <br /> VI.Tank /u ! 7 L°" ' cYl/ 3x-� 9B•b <br /> Capacity in Total 1l of Manufacturer 5 —' 97,9 <br /> Information Gallons Gallons of Prefab Site Steel Fiber- plastic <br /> New Existing Con- Con- glass <br /> Tanks Tanks trete strutted <br /> SrP f-r c 75'0 _ <br /> PrP- � ❑ ❑ � � <br /> VII.Responsibility Statement <br /> I,the undersi ed,assume res onsibillity for installation of the POWTS shown on the attachedlans. <br /> Plumber's Name(print) PlumbeC )s Signature(n tams; <br /> // PMP/MPRS No. <br /> Rr h p y /T 0 �/N Business Phone Number <br /> Plumber's Address(Street,City,State,Zip Code) ,. <br /> .k776C A�4v 3 s W ebjfwL <br /> 4/s`7 <br /> Y.- <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater <br /> pproved ❑Owner Given Initial Adverse Surcharge Fee) Date I ued ' Issuing gen i <br /> Determination ��a• s <br /> IX.Conditions of Approval/Reasons for Disapproval: Q <br /> fad 341-5 <br /> SBD-6398 R07/00 <br /> MAR 232001 U <br /> BURNETT COUNTY <br /> ZONING <br />