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p6tt't'TkGyT County <br /> Industry Services Division BURNETT <br /> ' 1400 E Washington Ave <br /> r t e Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> Madison,WI 53707-7162 -SOU <br /> U <br /> SHN-/s <br /> 12 <br /> Sanitary Permit Application State TransactionNumber <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit ��.y y RCtI I tai <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> JOHN&BARBARA DONLIN(LIFE ESTATE) 07-030-2-38-16-04-5 05-012-011000 <br /> Property Owner's Mailing Address Property Location <br /> 24520 LIND RD <br /> Govt.Lot 12 <br /> City,State Zip Code Phone Number /,, '/4, Section 4 <br /> SIREN,WI 54872 (715)349-5277 (circle one) <br /> T38N; R16WEorW <br /> 11.Type of Building(check all that apply) Lot# <br /> ® 7 l or 2 Family Dwelling-Number of Bedrooms �7 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number El Village of <br /> ® Town of SIREN <br /> III.Type of Permit: Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <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/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 642.86 642.86 98.0' <br /> .7 <br /> VI.Tank Info Capacity in <br /> $ C <br /> Gallons Total #ofManufacturer <br /> v <br /> Gallons Units ; 2 d `� <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank 1000 rt000 1 WIESER CONCRETE ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VIL Responsibility Statement- 1,the undersigned,Wsime ponsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI s S' MP/MPRS Number Business Phone Number <br /> CORY JACKSON 824339 715-566-2786 <br /> Plumber's Name(Print) 7 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 BLACK BROOK RD. WEBSTER,WI 54893 <br /> VIII.Court /De artment Use Only <br /> Approved Disapproved Permit Fee` Date Issued Issuing Agent Signat <br /> El Owner Given Reason for Denial S Iii• 5' 7" /ST- <br /> IX. <br /> 5 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete phos for the system and submit to the County only on paper not leas than 8 to x 11 inches in size <br /> SBD-6398(R03/14) <br />