Laserfiche WebLink
Safety and Buildings Division County �� <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> 1*isConsin <br /> Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 _ <br /> I.D.Number Plan <br /> Sanitary Permit Application State �14R8q <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(1 xm) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information 7 O ,J5 L•/) /L <br /> ?q <br /> Property Owner's Name Parcel# Lot#3 Block# 1.C9 5 <br /> 4-OW 4yowr/ o Wzto <br /> - <br /> Property Owner's Mailing Address Property Location <br /> QI yg %4, 'A Section fit <br /> City,State Zip Code Phone Number <br /> 1/ AJ �l�,Z /a.� /(circle <br /> 1/ r+ T i0 N; R `G E oric <br /> 11.Type of Building(check all that apply) <br /> 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> (/ <br /> ❑Public/Commercial-Describe Use t/A io-t?0 <br /> ❑State Owned-Describe Use ❑City_❑Village 5fownship of V"t. 141A.Cl <br /> 1II.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System <br /> y ❑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 System: Check all that apply) <br /> VNon-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.Dis ersallTreatmentArea Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 6G0 . & coo /cbv I ?OA <br /> Vl.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanis Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Unit (/W <br /> Dosing Chamber `yt <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PIut ber's Name(Pr t) Plumb ignature MP/MPRS Number Business Phone Number <br /> 5 /0 ff' , 85?95'� 7/f*-Ti t4- 0a02 <br /> Plumber's Address Street,City,State,Zip ode) <br /> G ;�lA /, velklo hr w ' k g <br /> VIII.County/Department Use Only <br /> Approved ❑Disapproved Sanitary Permit Fee(includes Groundwater Dat Issued I ing Agent Signatur o Stamps) <br /> Surcharge Fee) <br /> El Owner <br /> ,�O �� <br /> Owner Given Reason for Denial !J <br /> Ia.Conditions of Approval/Reasons for Disapproval <br /> APPROVED <br /> n R?. � <br /> Attach complete plans(to the County only)for the system on paper not less than 8l/2 x l l inches in All <br /> SBD-6398 (R. 01/03) <br /> Burnett County <br /> Land Services Department <br />