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-Nanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21, Wis.Adm. Code 201 W.Waihington Ave. <br /> VLconsinSee <br /> reverse side for instructions for completing this application PO Box 7302 <br /> Department of commerce Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> (Privacy Law,s. 15.04(1)(m)l (Submit completed form to county if not <br /> state owned. <br /> Anach complete plans to the county copy only)for the system,on paper not less than 8-I/2 x I 1 inches in size. <br /> County State Sanitary Perm't if iontop�previous applicau n State Plan 1.D.Number rj) <br /> r <br /> L Application Information-Please Print all In rmation Location: <br /> Property Owner Name Property Location <br /> �} �� '/ W 1/4 SW 1/4.S—)Z T WO,N,R11h7t or <br /> rlr- <br /> Property Owner's Mailing Address Lot Number Block Number <br /> City,State I Zip Code Phone Number Subdivision Name or CSM Number <br /> 5 Ower . WZ 5�801 1 ( 7f S ) 63S- 3 766 <br /> II Type of Building: (check one) ❑City <br /> Pl I or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑ Public/Commercial(describe use): ErTown of <br /> 7 State-owned S C o 1f )C <br /> III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road -A= <br /> A) 1. ❑New System 2. PKZeplacement 3. ❑Replacement of 4. ❑Addition to Parcel Tax Number(s) <br /> Svstem Tank Onlv Existing Svstem O 2 e 12 3 '0.2 -�00 <br /> B) 11 Perm[[Numbcr Date Issued <br /> A Sani[ary Permit was orevioush- issued <br /> IV.Type of POWT System: (Check all that apply) <br /> O.,Non-pressurized In-ground ❑ Mound ❑Sand Filter ❑ Constructed Wetland <br />❑Pressurized In-;round ❑ Holding Tank ❑Single Pass ❑ Drip Line <br />❑At-grade ❑Aerobic Treatment Unit ❑Recirculatin ❑Other: <br /> V Dis ersaUTreatment Area Information: <br /> 1.Design Flow(gpd) 2.DispersaWea 3.Dispersal Arca 4.Ail Application 5.Percola n Rate 6.System Elevati or( 7.Final rade <br /> Required Proposed Rate /sq.ft) (MinJinch) Elevation <br /> yso <br /> if 1 21 . 7 . 93-�6 700-97 <br /> q <br /> VI Tank Capacity in Total X of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks Tanks <br /> f-Je('SeJ' l000 � ��°� � I.J�ISer- <br /> 1�- ❑ ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> L the undersi ed,assume resoonsibili for installation of the POWTS shown on the attached plans. <br />?lumber's Name(print) ?XnbeesSigirtle(no stamps): MP/MPRS No. Business Phone Number <br /> ells F . SoW <br /> Ilumbces Address(s ity,State,Zip Code) <br />✓III County/Department Use Only <br /> ❑Disapproved Sanitary Permit fFe(Includes Groundwater ;71 <br /> d Issuing Sign ps) <br /> gApproved ❑Owner Given Initial Adverse Surcharge Fee) / ILI),Determination <br /> X.Conditions of Approval Reasons for Disapproval: <br /> a M ,: <br /> BURNETT COUNTY <br /> ZONING <br />