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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 X rye <br /> NY6sconsinMadison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ,S���S�i� (608)266-3151 5A4 t-1' -2L-.� <br /> Department of Commerce +'iNCgT-1$�g� <br /> State Plan I.D.Number <br /> Sanitary Permit Application <br /> 692t0'6 6.0261(00 <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law.515.04(1)(m) Project Address(if different than mailing address) <br /> c <br /> I. Application Information–Please Print All Information r►.lt- <br /> 11 0(07-5 <br /> Property Owner's Name Parcel# Lot# Block# <br /> Krim 4ekdk 6e1 I rau cr 0742-2-14-16-1315-61/74-oF6410 <br /> Property Owner's Mailing Address Property Location <br /> ZOO 7 eAgu'e 1s 4/ <br /> ,, v., Section /3 <br /> City.State Zip Code Phone Number <br /> AlNibtl W6 $eft 7/6--25,^76 l►7 T Ile) N: R iPircieW e) <br /> E orII.Type of Building(check all that apply) <br /> C:irl or 2 Family Dwelling-Number of Bedrooms Subdivision Name CSM Number <br /> 0 Public/Commercial-Describe Use <br /> 0 State Owned-Describe Use ❑City_❑Village T1'ownship of '(iGlje'1r✓ <br /> III.Type of Permit: (Check only one box on line A. Complete line 13 if applicable) <br /> A. 0 New System /�t1'{o of: <br /> ❑Replacement System ❑Treatment/Holding Tank Replacement Only Other Modification t Existing S e Ada 1 <br /> I li kevt .J 1 J)U ' Stph� ,i1 of' <br /> B• 0 Permit Renewal 0 Permit Revision 0 Change of 0 Permit Transfer to NewList Previous Permit Number and Date Issue <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apely) <br /> `g Non-Pressurized In-Ground 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil 0 At-Grade 0 Single Pass Sand Filter 0 <br /> Constructed Wetland 0 Pressurized In-Ground 0 Holding Tank 0 Peat Filter 0 Aerobic Treatment Unit 0 Recirculating Sand Filter 0 <br /> Recirculating Synthetic Media Filter 0 Leaching Chamber 0 Drip Line 0 Gravel-less Pipe 0 Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> — <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(so Dispersal Area Proposed(sf) System Elevation <br /> 1/9i -S 90 vo 930 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab . Site Steel ' Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tnnlre Tanks <br /> `l <br /> Septic or Holding Tank 3o Az) pr Z Lice `� <br /> Aerobic Treatment Unit `=I /v _ A41/4/'+' �•I 7 <br /> Dosing Chamber <br /> 1 VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> PlwKbcr's Name(Prkt) Plumber' aturGi � MP/MPRS Number Business Phone Number <br /> oys ieli - / <br /> 85716-g 7/5--56‘.- ozoz <br /> Plumber's AddA,4 <br /> Street.City,State,Zip ode) <br /> 40/ Odeibia 1k l Vekl icf Wis Ill?, <br /> VIIII.County/Department Use Only <br /> Sanitary Permit Fee(includes Groundwater Date ssu 1 in Agent S' nature tar s) <br /> rrApproved ❑ Disapproved <br /> Surcharge Fee) 315 06 12 /0 zDIDI <br /> 0 Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APPROVED 3, This 5,4,,,,►4„ wuAs-f be,.20 o fo Iled 60.v2 13 60 <br /> Ott ou,�td��c e( I.?A(i.�✓ pQfi�,�. a lECEDVEauAttach complete plans(to the County only)for the system on paper not less than 812 x 11 inches it <br /> DEC 16 1019 <br /> SBD-6398(R. 01/03) <br /> Burnett County <br /> Land Services Department <br />