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Safety and Buildings Division County <br /> AA 201 W.Washington Ave.,P.O.Box 7162 87 xrA-�" <br /> Asconsin Madison,WI 53707 6-3151 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 48 J SS <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(1)(m) Project Address(if different than is address) <br /> I. Application Information-Please Print All Information <br /> 0 <br /> Property Owner's Name Parcel Lot N Block N <br /> z:>0//n7 f S�2CEY FGA 0Ba -6-2c>S-6-7-so0 <br /> Property Owner's Mailing Address Property Location <br /> 377 3 51,A)/-C 2D 55 / <br /> VF ,/,., Sit/, , seetlm <br /> City,State Zip Code Phone N,u(m�ber <br /> �nN �C)/ �, / r(circleo <br /> 11.Type of Building(chick all that apply) T�N; RL_�E <br /> qCV <br /> 1 or 2 Family Dwelling-Number of Bedrooms . <br /> Subdivision Name CSM Number <br /> �— �— <br /> ❑ <br /> Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use ❑City_❑Villag Township of 54s> SS <br /> 111.Type of Permit: (Check only one box on line A. Complete line B If applicable) <br /> A. New System ❑ Replacement System y ep y ❑Treatment/Holding Tank Replacement Only 11 Other Modification to Existing System <br /> B. El Permit Renewal 11 Permit Revision ❑Change of L1 Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Tvine of POWTS System; Check all that apply) <br /> X,Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Welland ❑ Pressurized In-Ground ❑Holding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-leas Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(st) Dispersal Area Proposed(aQ System Elevation <br /> x3bo • -7 4a9 a q g-7-nit <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tonka Tsnka 7.ffsp <br /> Septic or Holding Tank 75� 75'D u <br /> Aerobic Treatment Unit Y\ <br /> Dosing Chamber <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plana. <br /> Plumber's Name(Print) Plum ignature MP/MPRS Number Business Phone Number <br /> as ��7o ��s-zs - 3,5-1=q <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 76 713 S- STI A0 3 S_ D#91J�Ao Cjo 5q e 30 <br /> VIII. <br /> 'inn <br /> e artment Use Only <br /> Approved /D❑ Disapproved Sanitary Fertnit Fee(includes Groundwater Date Issued Issu' Agent gnatu cops) <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> LEV <br /> NOV 1 22004 <br /> Attach complete plana(to the County only)for the system on paper not ksa Than 81/1 s 11 Inc i Ize <br /> BURNETT COUNTY <br /> SBD-6398 (R. 01/03) ZONING <br />