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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> 'Wisconsin <br /> reverse side for instructions for completing this application PO Box 7302 <br /> `Wisconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on paper not less than 8-1/2 x 11 inc ies in size. ` <br /> Cox State S i Pe i umber 10 Check if revision to previous application State Plan I. 3.Number <br /> I.Application Information-Please Print all Infor ati n Location: <br /> Property Owner Name J Property Lo ationG. <br /> r/ /� S ��/ /� Q/�/ lU�14 /4,S/ T3 ,N,WX(or <br /> Property Owner's Mailing Address Lot Number Block Number <br /> Gx) �30� w ?� <br /> City,State Zip Code Phone Number Subdivision 'Jame or CSM Number <br /> S PC o^-) e_ r GJ-X- ( )635--7-1 . 7 CS/r1 V P 3 <br /> Ilr Type of Building: (check one) ❑City <br /> K1 or 2 Family Dwelling-No.of Bedrooms: ❑Village <br /> Public/Commercial(describe use):_ f(Town of <br /> ❑State-Owned <br /> XRoai <br /> um Kg) 02 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 007 <br /> A) 1. ew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <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 ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑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 6.Syste Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> -3 o / 7 77, s <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Stet 1 Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> �cc Ddd — adv og <br /> orwesta <br /> ❑ ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Namet) / Plumber's Signature o stampsp MP/MPRS No. B siness Phone Number <br /> (pri <br /> Plumber's Address(Street,City,State,Zi ode) <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fe (Includes Groundwater Date Issued Issuin Ag t Si ature ps) <br /> Approved t Surcharge Fee} ^ <br /> 1Y C�ld <br /> X.Conditiouia1, <br /> pproval: V <br /> DEC 2 " 2002 L ' <br /> BURNETT COUNTY <br /> 7Q 4114 1 <br /> SBD-6398(R.07/00) <br />