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Safely and Bmldings Di,loon Coumy <br /> 201 R'. R'a,hinglon Ase-. P.O. Box 71(i_ <br /> iseonsin Mid1wn, Rl i 3'07 i I Sanuan Pemw nlber be filled.n by Co l <br /> Department ri <br /> of Commerce 1608) 66-3151 <br /> Sanitary, 5750 <br /> y Permit Application Slate Plan ID Number �p <br /> In acc,,rd with Comm 83.-I,Wls. Adm.Code,personal information you proclde <br /> may be used for secondpry purposes Pro acy Law,sl i0a11)Iml <br /> Proles AJJmss pl Jilfercm Than ivaJing address) <br /> I. :application Information—Please Print All Information <br /> t <br /> Property Owner's Name <br /> / O/ Parcel x Lot x Block x <br /> Property Owner's Mailing AJJres 01Z ZZ,01 om 0 <br /> Property Location <br /> City.Slate �� <br /> Zip Cute Phone NumNE Section�. Section Z J <br /> webstc� wr� 5y8�3 — '' <br /> �I I.Type of Building(check all that apply) �rJ 66-72Zfj T 1/6 N, R 15l ov <br /> IL I or'-Family Dwelling-Number of Bedrooms <br /> Subdivision Name CSM1I Number <br /> ❑ <br /> public Commercial-Describe Use <br /> ❑Stile Owned-Describe Use ��....-- <br /> _❑Vlllage WTownship of kAel <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) ❑Clty <br /> A. <br /> Ip-��--yy <br /> New System ❑ Replacement System ❑ Treatment:Holding Tank Replacement Only 11 Other Modification m Existing System <br /> B. ❑ Permit Renewal <br /> ❑ Permit Rev ivun El Change of Lm Previmus Pcrmn Number and Date Issued <br /> Before ExpirationS ❑Pernw Transfer to New <br /> Plumber Owner <br /> 1" Tv a of POKTS Svstem: Check all that apply) <br /> Non-Pres'sunzed In-Ground ❑ Mound>N inof suitable soil ❑ Mound<24m.of,unable sod ❑ At-Grade <br /> Constructed Welland ❑ Pressurized In- g ❑ Single Pass Send Filter ❑ <br /> Ground ❑ Holding Tank El Filler ❑ Aerobic Treatment Unit ❑Recirculating Sand Filler ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Dri <br /> V.Dis ersal/Treatment.area Information: p L'"` ❑Gravel-less Pipe 11 Other lesplainl <br /> Design ow(gpd) Design$oil Application Raietgpdsq Dispersal:Area Required(st) Dispersal Area Proposed Iso <br /> #3 System w <br /> -1Elevation <br /> " .Tank In o Capacity in Total Number Q/� d <br /> Gallons Manufacturer Prefab <br /> Gallons of Units Site Steel Fiber Plastic <br /> New Existing Concrete Consuucled Glass <br /> TaNrs TaNis <br /> Septic or Nulling Tank /Awls w,rs <br /> Aerobm Treatment Unit ✓VV osey G <br /> During Chamber / <br /> lill. <br /> Responsibility$[atemen[- 1,the undersigned,assume res <br /> pons <br /> Plumber's Nam (Pont) ibiliry for installation of the POA"TS shown on the attached plans. <br /> Plume PI bet's Signal e <br /> MP. ..R Number Business Phone Number <br /> Plumber's Address(Street,City,$tate,Zip Code) 2zs dy 41 7 <br /> Vll .Count%fDe artment Use Only <br /> Approved ❑ Disapproved Sanitary Penna Fee(includes Groundwater <br /> Surcharge Fee) a 'tied lyu, <br /> rs�� J i ILL IB ' r u$lamps) <br /> ❑ Owner Giv<n Reason for Denial <br /> 1\.Conditions of.Approval/. on.for Disapproval <br /> APR 2 2004 <br /> BURNETT COUNTY <br /> ZONING <br /> Au¢h slurp le phos po the County Doll)rut Ne syxom an paper not lass than tlIR s 1I inahn in ria <br /> SBD-6398 (R. 01/03) <br />