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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 /> Visconsin Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <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 /> Coty State Sanitary Perm' umber ❑Check if revision to previous application State Plan 1.D.Number <br /> r .� f <br /> I.Application Information-Please Print all Information Location: <br /> Zertyty Owner Name .Property Location <br /> /'t1V 6R I PL II EI14'5t: 1/4,ST'JON,RJY <br /> SW)W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> a4SB 614uck SPaIN6 Oa. ? <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> F*u 614112E Ljr Is H7o ( ifs ) 53s-- gs39 A11016 no- 4(r�,$e&e sLt6. <br /> II.Type of Building: (check one) ❑City <br /> I or 2 Family Dwelling-No.of Bedrooms: e;L ❑Village <br /> ❑Public/Commercial(describe use):_ �LTown of <br /> ❑ State-Owned 6C07Y <br /> Nearestfs k r R n <br /> Parcel Tax I yrpber(s1 70D <br /> G1 <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) 9tI <br /> A) 1. J&New 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> $) Pertni[Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> XNon-pressurized In-ground ❑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) 9L{ !!L� Elevation c] <br /> ydY, 6 N3f, �( . 7 l q (, s <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing trete strutted <br /> Tanks I Tanks <br /> 7�-o i LJI e e,e r ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plum is igna re o stamps): MP/MPRS No. Business Phone Number <br /> k—x 1301 M.�? a al0 SS 7i s 635 Sooa <br /> Plumber's Address(Street,City,State,Zip Code) <br /> A15�� ces�tcKDf-� 5 oo�e( (Vv, �v �o[ <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(I cludes Groundwater Date Issued Issu' g ent Signa (No stamps) <br /> pproved 11 Owner Given Initial Adverse Surcharge Fee) <br /> Determination ()LJ'03 <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> JUL 2 1 2003 <br /> BURNETfi' COUNTY <br /> SBD-6398(R.07/00) <br />