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vvisconsirn Madison. WI 53707 -7162 <br /> Site Address I <br /> Department of Commerce �2XYO 136 - /7 <br /> Sanitary Permit Application I Sanitary Permit Number 01` <br /> In accord with Comm 83.21 1,Wis.Adm. Code,personal information you provide T!( 0 <br /> mjav he used for sero ses Privacy Law,s15.oii(1)(m1 ❑ Check if Revision 43� <br /> I. Application Information-Please Print All Information <br /> Sate Plan LD. Number <br /> Property Owners Name <br /> Parcel Number <br /> Rene- Qe /arld o2O- 9075- 0/!00 <br /> Property Owners Mailing Address <br /> � p Property Location <br /> .17 3 11 sty' N <br /> City,Sax Zip Code Phone Numtxr A 4:S 33 T 4'V N.R /b E <br /> Lot Nut Block Number <br /> I <br /> / Subdivision Name CSbf Number <br /> wr°tls�z"r W S4� g�3 -7/S-866- `s - I <br /> II.Type of Building(check all that apply) <br /> A 1 or 2 Family Dwelling-Number of Bedrooms C� ❑City LC/V t/S <br /> ❑PubiWCommercial-Describe Use ❑V'ba� <br /> ❑Sax Owned (kro`vashils Op k(a <br /> Nearest Road <br /> III-Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> A. I Cl New 2 <br /> Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> System Tank S sum <br /> 13• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44,f Non-Pressurized In-Ground 21❑ Mound 47❑ Sand Filter 50❑ Consartcred Wetland <br /> 22❑ Pressurized In-Ground 41❑ Holding Tank 49❑ Single Pass 51❑DripLine <br /> 45❑ At-Grade <br /> 46❑Aerobic Treamteat Ung 49❑Recirculating 30❑Other <br /> V.D' Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area <br /> Soil Application on Peroolation Rax 7s:, <br /> levaon Final Grade i <br /> R�+� Proposed Ram(GalsJDays/Sq.Ft.) (Mia./Inch) Elevation 96 <br /> �00 6003 yr <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab $reel FiberGallons Gallons of Tanks Plastic <br /> New• Exicei" Concreteucxd Glass <br /> Tanks Tanks <br /> Septic or HoWinj Tank 500 - $Q <br /> S/Gat w �' <br /> Dosing C3amber <br /> VII.Responsibility Statement- L the undersigned,assume responstbtillty for installation of the pOWTS shown on the anachedlplans. <br /> Plumber's Name(Print) Plumber's Signature MPlMI I Number <br /> Business Phone Number <br /> � v �s 7 zs$s i 7��= gam- 467 <br /> )umbers Address(Street,City,sax,Zip code) <br /> 27 7 (a o 14-vv �S �g <br /> I , �483 <br /> Corm /De artment Use v <br /> I <br /> roved ❑ Disapproved Sanitary Permit Fee #lodes Groundwater Dax Issued Issuing at Ig re/ tamps) <br /> Surcharge Fee) �J g <br /> C1 Owner Given Initial Adverse _�G/f 6 _ <br /> Determination �y,�,y o3 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> J7Rt +J Utw-C /a & j?&t LAa P421!Coumy <br /> NSEx. J&a j j <br /> I <br /> Attach complete plans(to the only)for the syst paper 1/JRrt3 <br /> Inches <br /> SBD-6398 (R. OS/Ol) BURNETT COUNTY <br /> ZONING <br />