Laserfiche WebLink
Safety&Buildings Divisi <br /> Sallitar3 Pertttit Application 201 W. Washington A <br /> In accord reith Cmnm R321. �1`is. Adm Cade CO Box 73 2 <br /> ` $CQI�$I�If See reverse side for instructions for completing this application Madison. WI 53707-73 <br /> Personal infrrrnntion)oil provide may be used for secnodnry purposes (Submit completed limn to county if <br /> Dpilnrtment of Cornmeroe [Privacy La,\.s. 15.04(l)(m)J <br /> _ slate ow <br /> . <br /> Attach complete plans(lo the count) copy onl))for the System,on paper not less than 8-1/2 x I I inches in size. <br /> county Burnett Stale Sanitary P ani( a rr ❑ ckrif revi���recio s application State Plan I.b.NWRI}�i 5 <br /> 1.Application Information - Please Crint ail Informatioonn # Location: btSJol <br /> Property Owner Manic Property Locatlnov�, LIE I <br /> Terrence Hamann GL 1 114 1/4,S17 1 8 ,N,47 or w <br /> Pro erty OWner's Mailing Address Lot Number Block Number <br /> 78 Hill Farm Rd 4 na <br /> City,Stale Zip Code Phone Number Subdivision Name or CSM Number <br /> Hudson WI 54016 (715 ) 381-5459 CSM Vol 1 Pg 27 <br /> If Type of Bnilding: (check one) ❑City <br /> ❑Village <br /> P9 1 or 2 Family Dwelling–No. of Bedrooms•__ 3 _ X1 Town of Daniels <br /> l7 Public/Cnmtnercial(describe — <br /> ❑ State-owned <br /> III 'Type of Permit: (Check only one box on line A. Check box on line B if applicable) jtollircel <br /> Nearest Road <br /> A) 1. ❑New System 12. ® Replacement 13. ❑ Replacement of 4. ❑ Addit1 as Number s1)Tank Ont y Existin <br /> 006 - 2417 - 03 700 <br /> B) Permit Number Date Issued <br /> ❑A Sanitar Cermit was reviousl issued <br /> IV.'Type of POWT System: (Check all that appl)) ❑Sand Filter ❑Constructed Wetland <br /> ❑Non-pressurized In-ground ❑ Mound <br /> ❑Pressurized In-ground (RIlnlding lank ❑ Single Pass ❑ Drip Line <br /> ❑ At-grnde ❑ Aerobic I teannent Unit ❑Recirculating ❑Other: <br /> V DispersaUI'realment Area Information: <br /> I.Design Flow(gpd) =na <br /> 3 Dispersal Area 4.Sail Application S.Percolation Rate 6. S}'stem Elevation 7.Final Grade <br /> Proposed Rate(Gals/dayAq. R) (Min./inch) Elevation <br /> 450 na na na na na <br /> VI Tank Capacit) ill Total H of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons links Con- Con- f <br /> New Existing <br /> Crete stntcted <br /> Tanks Tanks — ❑ <br /> Ek ❑ ❑ ❑ <br /> 2000 -- _ 2000 1 Wieser Concret ❑— El.- ❑ ❑ ❑ <br /> VII Responsibility Statement <br /> 11 <br /> the undersigned,assume res onsibility for installation of the POW I S shown on the attached plans. 13miness Phone Number <br /> Plumber's Marne(Print) PI ,ber's Signature( stamp )� MP/FdPRS Nn. <br /> Donald Daniels MP 330/221593 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip('ride) <br /> PO Box 316 Siren WI 54872 <br /> Vlll Coll nty/ )epartment Use Only _ <br /> ❑Disapproved Sanitary Permit Fee hides Grou dwaler Uate Is ved Issuin eat at r o.tamps) <br /> proved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determin 'on <br /> IX. Conditions oy o t. royal: <br /> Pex- <br /> Nov <br /> ail �S a )0- p5 <br /> ZONING <br />