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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 �1)R tlJ E� <br /> NVisconsin Madison,WI 53707—7162 Sanitary Permit Number o be filled in by Co.) <br /> (608)266-3151 Yo Cb <br /> Department of Commerce <br /> Sanitary Permit Application State Plan I.D.Number CyQ <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)(m) Project Address(if different than mailing address) <br /> I. Application Information-Please Print All Information a92 �l 3 7o ,L)on LdKe- Aa <br /> t 75 <br /> Property Owner's Name Parcel# Lot# Block# <br /> j( •1�0 - /-/A P L O/9.420� -0 z <br /> Property Owner's Mailing Address Property Location <br /> O ro GA- TR /. uU� /., Section <br /> City,State nn11 '' // Zip Code II// Phone Number <br /> (rJ <br /> &sr Pm� yy ct.� W (.[�O�Y� 185- S- oZq0 <br /> (circl�e�o ) <br /> II.Type of Building(check all that apply) Subdivision Name CSM Number <br /> 11 or 2 Family Dwelling-Number of Bedrooms <br /> ❑Public/Commercial-Describe Use ❑City_❑VillageTownship of \ --..( VC)�)'v <br /> ❑State Owned-DescribeUsc <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A, ❑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 <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T of POWTS System: Check all that apply) <br /> Non-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.Dispersal/Treat nt Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> X00 4/29 `139. 3 9� ©� <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 /> Tanks Tanks C <br /> Septic or Holding Tank •75-0 -750 f F��Ou�7•s' <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P S1 atJ MP/MPRS Number Business Phone Number <br /> P2Ai� �- as ��7� ?>50 ?04- 3501/ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> /(0-7 / 3 s. 57�4)rE 4>/) 3c3- 6,4tv6 W; • St/D3v <br /> VIII.Cozen /De artment Use Only <br /> Sanitary Permit Fee(includes Groundwater Date Issued Issui Signatu tamps) <br /> Approved ❑Disapproved Surcharge Fee) j^ !J) <br /> ❑Owner Given Reason for Denial ��v <br /> IR Conditions of Approval/Reasons for Disapproval r, r <br /> JUN 1 8 2004 <br /> BURNETT COUNTY <br /> Attach complete plans(to the County only)for the system an paper not less than 81/2 x 11 Inches in size <br /> ZONtNG— <br /> SBD-6398 (R. 01/03) <br />