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ON COMPUTER/SCANNED <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See ruwersa side for for completing this application 15 Box 7302 <br /> Visconsin Personal information you provide may be used for secondary pun xnm Madison,WI3707-7302 <br /> Department of Commerce (pricey Law,s.15.04(lxm)] (Submit completed form to county if not <br /> ed. <br /> v <br /> Attach complete pis(to the county copy may)for the system,on paper not less d m 8-1)2 x 11 inches in size state own ) f <br /> County y Sr�ate Saeilsy['ttteitNuasber aerie b a4PSuation Stare Phne L D.Nnunbrr <br /> L Application Information-Please Print all Inf m matiON Location: <br /> Property Owner Name '/ Pwp�y Location p <br /> 5, ile- ©Il 411"'!l/4-S-&1/4,S-?�T3o,N>Rf r) <br /> Maim Amon LotNumber Block Number <br /> t;q,stme zipcoa Phone Number Subdivision Name or CSM Number <br /> Ff c6i,'C- ki I, I 6"ye3 `7 I ( ) C,- <br /> U.Type of Building: (check one) ❑City <br /> ❑ 1 or 2 Famt7y Dwelling-No.of Buxtrocras: ❑Village <br /> Town of PubfidCommeraal(desmtbe use):_ ? f� <br /> ❑State Owned zC? <br /> o7-of 4-a-M-15-35-505-600 -014 000 NeaestRoad �nn f <br /> Parcel Tax Numbers)� t . � <br /> III.Type of PermW (Check only one boa on line A. Check box on line B if applicable) <br /> A) 1. A New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Pennnt Number Due leered <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POW System:(Check all that apply) <br /> ❑Non-pressurized ln-ground WMound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-j u ❑Holding Talc ❑Single Pass ❑Drip I.inc <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other- <br /> V.Dispersalffreatment Area Information: <br /> 1.Design Flow(gA 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Paeoladon Raba 6.System Elevation 7.Fuua1 Grade <br /> Required Proposed Rate(GalsJday/sq.R li) (Minuch) Elevation <br /> ysC� Y� ys� r y � 7(- y17 <br /> VII.Tank Capacity in Total #of Manufac ura Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing caete strutted <br /> Tanks Tanks <br /> ❑ ❑ ❑ ❑ ❑ <br /> VHL Responsibility Statement <br /> I,the undersigned,assume ume responsibility for won of the POWTS shown an the attached plans. <br /> PlujQbces Nme(pr®t) S' stamps): MPMen No. Business Phone Number <br /> erns <br /> Plumbees Address(Street,City,State,Tap Code) <br /> DL Coantymepartment Use Only <br /> ❑Disapproved sandwy Permit Foe(Includes Gimumdwa to Date Issued lssumg ) <br /> C�Appimved ❑ Initial Adverse Suuchage Fee) � z` �11/rL� <br /> A Foo�W- W <br /> X.Conditions of Approval/Reasons for Disapproval: l <br /> BURNETT COUNT` <br />