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7DepartmFent <br /> Safety and 9uudings ulvision county <br /> sOnsin 201 W. Washington Ave., P.O. Box 7162 ��>/'�1GMadison, WI 53707-7162 Site Address <br /> of CommerceSanitary Permit Applicationsanitary PcrmttNumbern accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law, 15. 1)(m ❑ Check if Revision �7 <br /> I. AppUcatlon Information-Please Print All Information Sate Plan I.D.Number <br /> Property Owner's ame <br /> nn Parcel Number <br /> IfiL /1"oSsa� ✓' 01a-4aa9 - Da IS <br /> Property Owner's Mailing Address Property Location BOG <br /> �7 7 73` ,v4 5 e-^ ��• 4S u Nt'u:S T YQ N.R�S� <br /> City,Sate Zip Code Phone Number Lot Number <br /> Black;Itunber <br /> Subdivision Name CSM Numbe <br /> er ccr� 5 Y�93 8�d- �'�'�'7 _ <br /> II.Type or Building(check all that apply) <br /> ❑City <br /> ❑ 1 or 2 Family Dwelling-Number of Bedrooms _ <br /> ❑Village <br /> ❑Public/Commercial-Describe Use <br /> ❑Sate Owned Oftnship <br /> Nearest Road <br /> III.Type of Permit: (Check only one box on line A(numbering scheme for.internal use). Complete B if appl atilt)��' <br /> A. IONew 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use <br /> _System Tank Onl Existing System <br /> B• ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued <br /> IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) <br /> 44�*Mn-Pressurized In-Ground 210 Mound 47❑ Sand Filter <br /> 50❑ Constructed Wetland <br /> 22❑ Pressurized In-Ground 41 ❑ Holding Tank 48❑ Single Pass 51 ❑Drip Line <br /> 45❑ At-Grade 46❑Aerobic Treatment Unit 49❑Recirculating 30❑Other <br /> V. Die ersal/Trealment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./inch) Elevation <br /> s7i <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site <br /> Gallons Gallons of Tanks Sieel Fiber Ph aic <br /> New Existing Concrete Constructed Glass <br /> Tanks Tanks <br /> Septic or ttsralaarxw avv rJOD K�9 4J <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersigned,ustsme responsibility for installation of the POWTS shown on the attached pLsu. <br /> Plumber's Name(Pr t) Plumber's Si unbar MP/MPRS Number <br /> �J e— � gj Business Phon:Number <br /> !it! iTG/ tit/ 7 el <br /> Plumber's Address(Street,City,Sate,Zip Code) <br /> VII Count /De artment Use OnI <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing n[ natu Stan ps) <br /> Surcharge Fee) <br /> ❑ Owner Given Initial Adverse <br /> Determination <br /> IX. Conditions of Approval/Reasons for Disapproval <br /> OC 62004 <br /> II <br /> BURNETT COUNTY <br /> Attach complete pians(to she County only)for the system on paper not less than 81/2 x 11 inches in size NG <br /> SBD-6398 (R. 05/01) <br />