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Safety and Buildings Division County <br /> 201 NW.Washington Ave.,P.O.Box 7162 Vary <br /> ,��0 �,� Madis on,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 _ #4N-92.4 <br /> Sanitary Permit Application State Plan I..D../Nuumber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide 6{7 V 2 Z- <br /> may be used for secondary purposes Privacy Law,sl 5.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information Z.7225" �Qc <br /> Property Owner's Name Parcel# Lot# �I Block <br /> Ae 1 <br /> 1�ztN . 046- Z- o - .o, l <br /> Property 016vner's Mailing Address �jy� Property Location <br /> �2l1 r'`� '/4, '/., Section <br /> City,State Zip Code�j Phone Number <br /> dr <br /> II.Type of Building(check all that apply) V 7 ✓�D T N; R E gfWJ <br /> ❑1 or 2 Family Dwelling-Number of Bedrooms L U_, Subdivision Name CSM Number <br /> 19 Public/Commercial-Describe Use ti/ti)►'jP S �'r I <br /> ❑State Owned-Describe Use ❑City_❑Village[*ownship of 404 Qq <br /> 1I1.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System ❑Replacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS Sys tem: Check all that a 1 <br /> V1 Non-Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media 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(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 9I 1D <br /> V1.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank. <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigned assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plm ber's Name(Pr t) Plumber' r ature,,, MP/MPRS Number Business Phone Number <br /> BSI 9,0-y S <br /> Plumber's Ad dress Street,City,State,Zip ode) <br /> G iAJik V <br /> VIII.County/Department Use Only <br /> A proved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date issued Tz7 <br /> Agent Si$�ature o ps) <br /> Surcharge Fee) ' t�- I-^^IQ❑Owner Given Reason for Denial 11LL OON/1//��//" <br /> I\.Conditions of Approval/Reasons for Disapproval <br /> • f�cncwtd o� <br /> frown I I- ►- �ort� <br /> APPROVED <br /> I,n 7 4 gniq n <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 111 hes size <br /> BURNETT COUNTY <br /> SBD-6398(R. 01/03) ZONING <br />