Laserfiche WebLink
Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 a rfl�I-I <br /> `�SCOnS%n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce (608)266-3151 4-38 331,9 <br /> Sanitary Permit Application nate Plan I.D.Number - <br /> In accord with Comm 83.2 1,W is.Adm Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(iXm) - <br /> -- J" <br /> L Application Information-Please Print All Information � ^ t� <br /> p( I OI'}Z-Zo7- Ob fa BO <br /> Property Owner's Name Parcel# Lot# Block d <br /> ry,111c , 0"et-.ST2oM <br /> Property Owner's Mailing Addr - Property Location 16 <br /> 2H Z02— e.LSsYs IZoRD z "Y2— <br /> 5tt) <br /> City,State Zip Coda Phone Number '/., ne 1/4, Section '/ <br /> wGbS�eR _ (circle <br /> T 38 N; R�S_E orn1ro <br /> Subdivision Narne CSAR A='�r <br /> ❑City_❑Village 2fownshipof <br /> L 77; <br /> III. Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> .i New SystemS--.. <br /> ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing Svstem <br /> B ❑ ate!.sued Permit Renewal Revision Change of ❑Permit Transfer to New List Previous Permit Number and D <br /> Before Expiration Plumber Owner <br /> -. ._----.L-------------- --- <br /> IV. Type of POWTS System: (Check all that apply) <br /> XI Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ Cormntcted <br /> Weiland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ Recirculating SN9lthelic Media <br /> Filter ❑Leaching Chamber ❑Drip Line Gravel-less Pipe ❑Other(explain) <br /> V. Dispersal/Treatment Area Information: <br /> Design Flow(gpd) I Design Soil Application Rate(gpdsi) Dispersal Area Required(at) Dispersal -----_---- - -- - - <br /> Area Proposed(at) System Elevation <br /> — - __ <br /> VL Tank Info Capacity in Total Ntanber Manufacturer Prefab Site Steel Fib—er -PlasUc <br /> ,. Gallons Gallons of Units Concrete Constructed Glass <br /> 1 New Existing <br /> TWcs Tanks <br /> 0o 00 <br /> Aerobic Treatment Unit <br /> Dosmg Chamber - <br /> VII. Responsibility Statement- I,the undfirsigned,assume resyQsibillty for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print y lum s ignature MP/MPP dumber Business Phone Number <br /> M81K SEP i Ie & LACAVAT10 a 5/8 7 <br /> C, INTY -J-t <br /> Plut, Code) <br /> r <br /> VU). <br /> Countyapartment se Only <br /> Sanitary Permit Fee(' cludes Groundwater Date Issued Issuin t Signature o Stamps) <br /> Approved ❑ Disapproved Surcharge ) <br /> tua Fee <br /> [I Owner <br /> � <br /> Owner Given Reason for Denial act e clo ' O(r Q 3 <br /> DC Conditions of Approval/Reasons for Disapproval <br /> RECEIVED <br /> AUG 13 2003 <br /> Attach complete plans(to the County only)for the system on paper not ieu than 81/2 z 11 Inches in she <br /> BURNETT COUNTY <br /> ZONING <br />