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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.2 1,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Visconsin personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce (Submit completed form to county if not <br /> - [Privacy Law,s. 15.04(1)(m)] state owned. <br /> Attach complete plans to the county copy only)for the system,on paper not less than 8-1/2 x 11 inches in size. <br /> County State Sanit e�i umber ❑CI�eEk if revis'T to previous application State Plan I.D.Number '� <br /> �7 <br /> I.AppTication Information-Please Print all Information u Location: Do <br /> Property Owner Name Property Location lb <br /> // _/�- <br /> 1/4 1/4,a ,N,WJE o W <br /> PropertyOwner's Mailing Address Lot Number Block Numbe <br /> X43V <br /> A <br /> City,State Zip Cade Phone Number Subdivision Name or CSM Number <br /> NO W66 t✓/- 54_T_ l< ) 93-3 O AKA ,v 7 v V. <br /> II.Type of Building: (check one) ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): $Town of <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) Ne st Road <br /> A) I. New System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Nu er(s) <br /> System Tank Only Existing System 4. :2 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> �.I�V(.Type of POWT System: (Check all that apply) <br /> �C�Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding 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 /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> *z qoo 90C> . 5 r--f 16.1 ?%-) <br /> VI.Tank Capacity in Total I #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> �Pr[� l000 -- Imo � NbtZt,J�sl,o ❑ ❑ ❑ ❑ � <br /> ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> 1,the undersigned,assume restionsibility 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 /> umbers Address(Street.City State,Zip Co e) <br /> 2'17(0 3S W£Ssr U11• S4$93 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date I sued Issuing Agent igna e s ps) <br /> roved ❑Owner Given Initial Adverse Surcharge n <br /> Determination 7 <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> (� �J <br /> BURNZON COUNTY <br />