Laserfiche WebLink
Sanitary Permit Application I Safety&Buildings n <br /> ' 1n accord with Comm 83.21,Wis.Adm. Code 201 W.Washingt Ave. <br /> See reverse side for instructions for completing this application PO B 2 <br /> ` isconsin personal information you provide may be used for seconds Madison,WI 5370 - 2 <br /> Department of Commerce Y p Y secondary purposes ( t <br /> [Privacy Law,s. 15.04(I)(m)] Submit completed form to cou <br /> state o .) <br /> Attach complete plans to the county copy only)for the symem.on paper not lesq than 8-1/2 x l l inches in size. <br /> County State Sanitary Permit be Ch ck r isioq tp prgvious appli ion State Plan 1.D.Number <br /> I.A ication Information-Please Print all Inf rma on Location: <br /> Property Owner Name Pro erty Location <br /> 1/4 WI/4.S 7 T ,N, or Q <br /> PropertyOwner's Mailing Address of Number Block Number <br /> !Z670 -6Ire ns RD_ <br /> City StateZi Cade Phone Number Subdivision Name or CSM Number <br /> 91� Gly 549g3 <br /> ( ) <br /> II Type of Building: (check one) " ❑City <br /> 1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> ❑ Public/Commercial(describe use): -- Mown of� 0� <br /> ❑ State-Owned <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if zrpplicable) Nearest Road <br /> Of <br /> A) 1. ❑New System 2. keplacement 3. ❑ Replacement of 4. ❑ Addition toParcel Tax M umersb <br /> System Tank Onl Existin System Q 0 <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 ❑ Holding Tank 13 Single Pass ❑Drip Line <br /> ❑ At- ade ❑Aerobic Treatment Unit ❑ Recirculating ❑Other: <br /> V. Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate i.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 500 6 r--d ¢SS q9 78 /0/. 7 <br /> VI.Tank Capacity in Total #of Manufacturer Prefab Site Steel I Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> C 00'0 /000 <br /> ❑ ❑ ❑ ❑ <br /> ❑joe <br /> ❑ ❑ ❑ <br /> VII.Responsibility Statement <br /> I,the undersigned,assume responsibilitv for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plumber's Signature(no stamps): MP/14PRS No. Business Phone Number <br /> cs{A,2> a•✓ ?2585/ S &-.41S_7 <br /> Plumbers Address(Street,City State,Zip Code) <br /> 2.77(0 3S W676M WI. 54893 <br /> VIII.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuirya%AQent Signature <br /> ❑ <br /> A roved Owner Given Initial Adverse Surcharge Fee) / (X^�¢( -nC, <br /> pp Determination ��n� <br /> IX. onditions of Approval/Reasons for Disapproval: <br /> RECEIVEn <br /> SBD-6398 R07/00 JUN 19 2002 <br /> BURNETT COUNTY <br /> ZONING <br />