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Safety and Buildings Division County <br /> ®r 201 W.Washington Ave.,P.O.Box 7162 19 by <br /> f j,C,_ <br /> sco s' Madison,WI 53707—7162 Sanitary ennitPittmber(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 <br /> Sanitary Permit Application State <br /> / 6Plan <br /> hLD..No <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide (� j2 <br /> may be used for secondary purposes Privacy Law.s15.04(1)(m) Project Address(if diferent than mailing address) <br /> 1. Application Information—PleasePrintAllInformation <br /> 4L UZ �!_ 0,0-5z <br /> Property Owner's Name le. <br /> '001 <br /> Parcel J Lott Block g <br /> 16 <br /> Property O+vncr's Mailing Address Property Location <br /> City,State �L J� � ± Zip !` Phone Number 'A, %= Section <br /> I� i O�j•72V /u� trcfe <br /> I I.'Type of Building( teck all that apply) T 7b N, R E tV <br /> ❑ 1 or 2 family Dwelling-Number of Bed oms Subdivision Name CS,M Number <br /> Public/Commercial-Describe Use N /�; O/re s'G <br /> ❑State Owned-Describe Use ❑City_❑Village ITo%,.msltip of <br /> Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑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 /> i Before Expiration Plumber O+vncr <br /> Iv.Ty ystem: (Check all that a Iv) <br /> K Non-Pressurized in-Ground ❑Mound>2Y in.of suitable soil ❑Mound<24 in.of suitablo soil ❑At-Grade <br /> - ❑Single Pass Sand Filler ❑ <br /> Constructed Wedand ❑Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Falter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Dri Line ❑Gravel-less Mile <br /> V.Dis ersal/Treatment Area Information: <br /> p Other(explain) <br /> Design(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so)77T <br /> posed(sf) System Elevatio <br /> ffyy • 072 ,,Z 3? _ 7 <br /> VI.Tanitinio Capacity in Total 3umber Manufacturer Prefab Site Steel Fiber Gallons Callous of Units Plastic <br /> Nero ;&RTMR► Concrete Conswcted Glass <br /> Tanis 1lt.de- <br /> Scptic or Holding Tani 000 _/`X 7� <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the understWan assume responsibility[Or installation or the PONYTS shown on the attached plans. <br /> Phu bcr's Name Plumber' i ature MP/ftdPRS Number <br /> / Business Phone Number <br /> Plumber's Address ips Street,City,State,Z ode s` 1� 71� 50& Fgo2 <br /> /71 <br /> V III.Court ID nt•tment it—Onir <br /> proved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date is ed Is i Agept Si nature s} <br /> Surcharge Fee) 315.00 10 <br /> ❑Owner Given Reason for Denial `l <br /> IX.Conditions of Approva)/Reasons for Disapproval <br /> All sh&c covtoGH o5 are 4a be <br /> C 4,.# S7 8 <br /> APPROVED9 <br /> Attach complete plans(to the County only)ror the system an paper not l as than al/2 x 1I inches in <br /> M-6398(R. 01/03) Burnett County <br /> Land Services Department <br />