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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> iseonsin Personal information you provide may be used for secondary purposes Madison,WI 5370 -7302 <br /> Department or Commerce (Submit completed form to <br /> [Privacy Law,s. 15.04(I)(m)] (SP county if not <br /> state owned, <br /> Attach complete plaris to the county copy only)for the system,on paper not less than 8.1/2 x 11 inches in size. t� <br /> C L / State Sanitary Permit Number Check i(regiaion to previo=a�cation State Plan(.D.Numb g <br /> L Application Inforrmmation-Please Print all Information Location: <br /> / <br /> Property Location Name IeeJ-S'74� V 4r S44lGI14 S-) �(�-N,Rl <br /> µ+ W N <br /> Ppcny Owner's Mailing Address Lot Number Block Number <br /> A _DO wood 13_)`_ <br /> , tate Zip Code Phone Number Subdivision Name or CSM Number <br /> rt,4, /'✓?Y) 1 15-So <br /> 11. Type of Building: (check one) 7 ❑City <br /> A I or 2 Family Dwelling-No. of Bedrooms ❑Village <br /> ❑ PubliGCornmercial(describe use): KTown of f <br /> ❑ State-Owned tulooU' <br /> III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nea est Roads <br /> C1 <br /> A) I New System 1 2. ❑Replacement 3. ❑Replacement of 4. ❑Addition to Farce Tax Number(s) <br /> System <br /> Tank OnlyExistin_ System ­c),S I <br /> B) Permit Number Date Issued <br /> ❑ A Sanitary Permit was previously issued <br /> IV. Type of POWT System: (Check all that apply) <br /> ❑ Non-pressurized In-ground ❑ Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑ Pressurized In-ground JKHolding Tank ❑Single Pass ❑ Drip Line <br /> ❑ At- ade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V. Dispersal/Treatment Arca Information: <br /> I Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation ]7_.Fnal GradeRequired Proposed Rate(Gels./day/sq.0.) (Min./inch) ation <br /> Asn <br /> VI. Tank Capacity in Total N of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> zoo t0 1 °se <br /> ❑ ❑ ❑ ❑ ❑ <br /> I <br /> VII. Responsibility Statement <br /> 1,the undersigned,assume res onsibili for installation of the POWTS shown on the attached tans. <br /> Plumber's Name pri Q PI nbers Stgnat re( tamps): MP/MPRS No. Business Phone Number <br /> lS 04r _ �i C e 1 LW- Oil- <br /> Plumber's Address(Street, ity,Slate,Z� code) <br /> � <br /> V 11.County/Department Use Only <br /> Disapproved Sanitary Permit F ncludes Groun&water Date ssued Issuing A nt Si ; t r o to <br /> .Approved1115-1 <br /> ❑Owner Civen Initial Adverse Surcharge Fe 7l'l` <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398 R07'00 <br /> F , <br /> NOV _ 1001 <br /> BURNETT COUNTY <br /> ZONING <br />