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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 /> \� See reverse side for instructions for completing this application PO Box 7302 <br /> IV/SCOnS/n Personal information you provide may be used for secondary purposes Madison,W153707-7302 <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 inches in size. <br /> CountyState Sanitary Permit Number �q he if revisiog,to revious application State Plan 1.D.Number t�- <br /> u - a d )2— 9005 tT <br /> I.Application Information-Please Print all Information Location: 7' <br /> Property Owner Name Property Location �j� /Q' ZIP <br /> yt t 1 t �-2.b0 I-C J()tl I IS tT \ G-1/4 N(�(.i/4,S M3O ,N,11 E W J <br /> Property(wner's Mailing Address Lot Number Block Number <br /> I(S51:)- N Slul.z -D r. col i c+ S <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Grot4 �sbvr -S ( �1S ) X10 <br /> II.Type of Buildi : (check one) '` ❑City <br /> 19 1 or 2 Family Dwelling-No.of Bedrooms: Y ❑Village <br /> ❑Public/Commercial(describe use):_ Q!Town of Q <br /> ❑State-Owned W OD J V- I V PY <br /> Nearest Road <br /> N, (wi.e fit, <br /> Parcel Tax Number(s . ,-2., -01 9t, <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. ❑New 2. KReplacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) 11Pemtit 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 Pt 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.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> (oC)o 600 ( Oc) 1 97. 1 W-'Ci <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks Tanks <br /> 121:1 <br /> L 17 <br /> ❑ ❑ ❑ ❑ <br /> VII .Responsibility Statement <br /> I,the undersigned,assume responsibil' for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) PI bens Signature o s ps): MP/MPRS No. Business Phone Number <br /> el s oev z2su �� ��� 6a <br /> Plumber's Address(Street,Citt,State,Zip Code) <br /> S L""\ <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Is s ' g t o stamps <br /> $f Approved ❑Owner Given Initial Adverse Surcharge Fee) <br /> Determination %(�( <br /> X.Conditions of Approval/Reasons for Disapproval: DEC 3 <br /> i <br /> BURNETT COUNTY <br /> ZONING <br /> SBD-6398(R.07/00) <br />