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Safety and Buildings Division County <br /> an 201 W.Washington Ave.,P.O.Box 7162 U <br /> Nvi c' onsin Madison,WI 53707-7162 sanitary Pettit Number(to be filled in by Co.) <br /> De artment of Commerce (60$)266-3151 2 <br /> Sanitary Permit Application State Plan I D.Num/bei <br /> In accord with Covera 83.21,Wis-Adm_Code.personal information you provide && 7(O <br /> may be used for secondary purposes Privacy Law,sl5.04(lxm) Ptoject Address(if different than mailing address) v <br /> I. Application Ihtformation-Please Print All Information Q <br /> C0� a�s�a (Q-5150, 1DK�v� ec v • �' <br /> Property Owners Name Parcel# Lot# Block# <br /> Property Mown<rs Meering Ara n - 612 <br /> Property Location 3" ` L <br /> 1'6, 6 (063 �t �a <br /> City.State Zip Code Phone Number _K Section - <br /> L1 ��+ '� �y -wit <br /> SCJ O T c7 ! N: R�B or + ) <br /> IL Type of Building(check all that apply) <br /> 1 or 2 Familyms Subdivision Name CSM Number Dwelling-Number of Bedroom /� ^ <br /> Public/Co moercial-Describe Use I-ASI n T •6AUf <br /> Stare Owned-Describe Use Chty_ Village Township of/t/Iii:�6/U <br /> IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A New System y Replacement System Treatment/Holding Took Replacement Only Other Modification to Existing System <br /> B• Petmit Renewal Permit Revision Change of Permit Transfer to New list Previous Permit Number and Date Issued <br /> Before Expiration Plttrnber Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> Non-Pressurized In-Ground Mound_>24 in.of suitable soil Mound<24 in.of suitable soil At-Grade Single Pass Sand Filter <br /> Constructed Welland Pressurized In-Ground Holding Tads Peat Filter Aerobic Treatment Unit Recirculating Sand filter <br /> Recirculating Synthetic Media Filter Leaching Chamber Drip line Geavel-less Pipe Other(explain) <br /> V.Dispersalfrreatrueart Area Information: <br /> Design Plow(gpd) Design Soil Application ltate(gpdsf) Dispersal Area Required(sf) Dispersal Area proposed(sf) I System Elevation <br /> r - <br /> VL Tank Info Capadty in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons. Gallons of Units Cohnctete Constructed Glass <br /> New Exist ag <br /> Tanks Teaks <br /> septic or holding Talc Oe)O 3000 WGE� <br /> AcrobicTteannem Unit <br /> Dosing Chancier <br /> VII Responsibility Statement-I,the undersigp4 assume resp9tasibililty for LbIalla' of the POWTS shown on the attached plauL <br /> Plumber's Name(Print) s umber <br /> �� �)L Business Phone Number <br /> Z3ZiZ 7/5-2M-3l4 <br /> Plumber's Address(Sweet,City,State,Tip CoadV V - <br /> P.b. Zn x Zi6 bgaSeK W1 54u)2 141 <br /> VDI.Conn /De ailment Use Only <br /> eDisapproved Sanitary Permit Pec(includes Groundwater Date Issoiog sign Stamps) <br /> �"yer� Smehare Fee) ODS ($ 6 ' <br /> Owner Given Reason for Denial - <br /> UL Conditions of Approval/Reasons for Disapproval 2 j <br /> OCT 1 5 2004 r <br /> BURNETT COUNTY <br /> ZONING <br /> AM&maiplete plans(to the County oily)for the slate n oa papv Not less than$lax it inches in size <br />