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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> jsCO��"',� Madison,WI 53707—7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 Q�J..- <br /> Sanitary Permit Application State Plan I.D.Nummber <br /> In accord with Comm 83.21,Wis.Adm_Code,personal information you provide 626:W <br /> may be used for secondary purposes Privacy Law,s I S.04(1)(m) Project Address(if different than mailing address) <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# Lot# (�Block# <br /> 4-, n/ 7WV41- a -Z7-�/5-Jf = gaoo <br /> Property Owner's Mailing Address Property Location Y} <br /> tT i;^ %., V., Section 7 <br /> City,State Zip C Phone Number <br /> /V 1'5�/7_1 R circle <br /> 1I.Type of Build' g(check all that apply) <br /> TAB N, Eo <br /> Ur 1 or2 Family Dwelling—Number oFBedrooms 71 Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> ❑State Owned—Describe Use Poly..OViliage Wownship of <br /> If 1.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑New System CYReplacement System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System <br /> B. ❑Permit Renewal ❑Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Cheep all that apply) <br /> ❑Non—Pressurized In-Ground ❑Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑At-Grade ❑Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑Pressurized In-Ground ItHolding Tank ❑Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information- <br /> Design <br /> �Flow <br /> (ggpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> Vl.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks I Tanks <br /> Septic or Holding Tank <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement—I,the undersigned,assume rosponsibitity for installation of the POWTS shown on the attached plans. <br /> Plw ber's Name(Print) / Plumber' ture�� MPIMPRS Number ss <br /> 5 /oi/t Busine Phone Number <br /> � It - ��%� Z7-01 <br /> Plumbers Address Street,City,State,Zip ode) <br /> G gin/1k / l cb err w ' 7-6 ? <br /> VIII.County/ c artment Use Only <br /> pproved ❑ Disapproved Sanitary Permit Fee{includes Groundwater Date SulIs g Agent Signatur (N St ps) <br /> Surcharge Fee) pp 'I <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> APPROVED <br /> 4q s <br /> D <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 s I I inches i UZE <br /> SBD-6398(R. 01/03) Burnett County <br /> Land Semices Department <br />