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Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 <br /> Visconsin Madison,WI 53707-7162 Six Address <br /> De artment of Commerce <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide El Check if Revision 42-5701 <br /> may be used for secondary purposes Privacy Law,sl5. 1 m <br /> I. Application Information-Please Print All Information State Plan I.D. Number <br /> Property Owner's Name Parcel Number <br /> SA-ro I us C OzD q4co OW00 <br /> Property Owner's Mailing Address J Property Location <br /> 15oSi ��'l ✓O/" AV, S - �� �k S6:S/4-5T 410N,R I <br /> City,State Zip Code Phone Number Lf r umber Block Number <br /> M()1 _ f J SA.7 �I 2 497 _75 31 Subdivision Name CSM Number <br /> R.Type of Building(check all that apply) 1 ULaG- / <br /> ❑City <br /> or 2 Family Dwelling-Number of Bedrooms <br /> 3 <br /> ❑Village <br /> ❑Public/Commercial-Describe Use <br /> ownship <br /> ❑State Owned Nea st Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for internal use). Complete line B if applicable) <br /> 1 ew 2 C1Replacement System 3 11Replacement of 6 11Addition to For County use <br /> Sy stem I Tank Only Existing System <br /> B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV.Type of Permit: (Check all that apply)(numbering scheme is for interval use) <br /> 44�Non-Pressurized In-Ground 210 Mound 47❑ Sand Filter 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade i <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) �� D Elevation <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> KTanksTank:s <br /> Septic or Holding Tank (vOODosing ChamberD'D <br /> VII. Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> � y �s - I - -Z $S 115 566- 44-S-r <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 27 7 (o 0 f+w 3S �B �¢S 3 <br /> VIII. Count /De artment Use <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing o[ gnature Stamps] <br /> Surc ge Fee) <br /> ❑ Owner Given Iridal Adverse ) A T /1�1 �{,�,D� <br /> Determination O-7J V V[/ c� <br /> IX.Conditions of Approval/Reasons for Disapproval RECEIVED <br /> T 2003 <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 Inches in she <br /> BURNETT COUNTY <br /> SBD-6398 (R. 05101) . ZONING - <br />