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Sanitary Permit Application Safety&Buildings iyt <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washin C. <br /> See reverse side for instructions for completing this application PO 302 <br /> V11isconsin Personal information you provide may be used for secondary purposes Madison,WI 5 7302 <br /> Department of Commerce (Privacy Law,s. 15.04(1)(m)] (Submit completed form to coup not <br /> state d. <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•S ri�ry Perp it Number ❑Check if revision o previous application State P L D.Number 1 <br /> 1.Apilfication Information-Please Print all Information Location: <br /> Property Owner Name Property Location <br /> 1/4 1/4,S T ,N,ttl or W <br /> Property Owner's Mailing Addrr4s Lot Number Block Numbe <br /> 3 S 8 ISI tnrc'" Cr3 2 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> S- A>+ RQZ5r 14 V, 14-0!51 <br /> 11..Type of Building: (chikck one) ❑C`ty <br /> ;4 1 or 2 Family Dwelling-No.of Bedrooms: <br /> ❑Village <br /> ❑ Public/Commercial(describe use): ;WT of ,r <br /> ❑ State-Owned J <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) aygbt gpad ��- a_ <br /> A) 1. )hew System 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Parcel T umber(s) <br /> System Tank Only Existing System evti !v5D 03 500 <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> ❑Non-pressurized In-ground Nvlound ❑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 Rale 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 'Aco300 1. 0 q9 2 /0/.0 <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 /> 3�t c 75D <br /> c <br /> goo SVC) ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MPMIPRS No. Business Phone Number <br /> A0.4441-5. 07 <br /> Plumber's Address(Street,City State,Zip Co e) <br /> 277(00 3S W£>35r lJi- 54$93 <br /> VIIl.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Iss Agent Si arure.(No stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination -� <br /> IY. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07/00 <br /> BURNETT COUNTY <br /> ZONING <br />