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Safety and Buildings Division uuunr' <br /> 201 W. p <br /> Washington Ave., P.O. Box 7152 3"-fl 8� <br /> Wisconsin Madison, WI 53707 -7162 Site Address ---- — "" <br /> Department of Commerce _ <br /> Sanitary Permit Application Sanitary Permit Number <br /> In accord with Comm 83.21, Wis.Adm. Code,personal information you provide <br /> y be used for secondary purposes Privacy Law 15.04 t)(m) 11 Check if Revion <br /> is <br /> ma4 <br /> I- Application Information-Please Print All Information State Plan LD. Number b —I__ <br /> Property Owner's Name Parcel Number <br /> Whr3 eren <br /> Ad <br /> „ ,e /YlBthedisf Ca:M U3�1 /S/( 057oD <br /> Property Owtser s Mailing Address Property location <br /> 110.50 W Ai3 er/„ 106,&-f Rat• N u;S It T 37 N. R le � <br /> City,Sure Zip Code Phone Number Lot Number Black Number <br /> Subdivision Name CSM Numbt <br /> _Freeferic ftJr 5,4937 7SS-337- ff q Gbi+�, <br /> 11.Type of Building(check all that apply) <br /> t1 Daly(9 1 or 2 Family Dwelling-Number of Bedrooms d' ❑V01agc _ <br /> ❑PublidCommercial-Describe Use RTownship r/ad Z& <br /> ❑Sate Owned Nearest Road <br /> WhN errqB �ne3 <br /> III.Type of Permit: (Check only one box on line A (numbering scheme for internal rue). Complete line if applicably.) <br /> A. 1 ❑ New 2OReplacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> S stem Tank Only Existurg System <br /> B. ❑ Check if Saniury Permit Previously Issued Permit Number Date Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44j? Not-Pressurized In-Ground 2111 Mound 47❑ Sand Filter 50❑ Constructed Weiland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑ Drip Linc <br /> 45❑ At-0radc 46❑Aerobic Treamsnt Unit 49❑Recirculating 30❑Other _ <br /> V. Dispersal/Treatment Area Information: <br /> Design Fiou (gpd) Dispersal Area Dispersal Arca Soil Application Percolation Race System Elevation Final Grade <br /> Required Proposed Ram(Gals./Days/Sq.Ft.) (Min./Inch) 93•f— Elevation <br /> 3 0o vd 9 ti3s• ti . � — 9 f.6 <br /> VI. Tank Info Capacity in Toul Number Manufacturer Pre Cab Site Seel Fiber PL: tic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Ex nu” <br /> Taroks Tal _ <br /> Septic or}luldina Tank 7S-b 7SO <br /> Dminy CbamMr SOQ SOO <br /> VQ. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached pl..as. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phon:Number <br /> C K //v k,„f /2-zee <br /> Plumber's Address(Street,City,Sure. Zip Code) <br /> - 7760 //.r 3-f-- <br /> NTH. Count /De artment Use Only _ <br /> ❑ Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwamr Date Issued Issuin Signatu o Sul ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse A f <br /> Determination <br /> U(. Conditions of ApprovaV <br /> I550sap ars A Stn9(e �ci.„r!r QeWe cer wrtea( by k)h,$e&,uy Pines1- a,AkaT As k fLbltr `4,LITy. <br /> j , <br /> Attach compiete plana(to the County only)for the system on paper not leas[h 2 s 11 inches to sire <br /> SBD-6398 (R. 05/01) BURNETTCOUNTY <br /> ZONING <br />