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County <br /> Industry Services Division Bumett <br /> 1400 E Washington Ave <br /> Sanitary Permit Number(to be filled in by Co.) <br /> =I <br /> t� P.O. Box 7162 <br /> Madison,WI 53707-7162 Ll� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 2947919 <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(I)(m),Seats. 7775 Tewalt Rd <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Jerome Tewalt et all 07-030-2-38-16-20-5 001-011000 <br /> Property Owner's Mailing Address Property Location <br /> PO Box 16 <br /> Govt.Lot I <br /> City,State Zip Code Phone Number /., /., Section 20 <br /> Siren,WI 54872 715-349-2861 (circle one) <br /> T38N R16EorW <br /> IL Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 3 1 Subdivision Name <br /> ❑Public/Commeroial-Describe Use Block# <br /> El City of <br /> ElState Owned-Describe Use <br /> FSM <br /> Number ElVillage of <br /> ® Town of Siren <br /> III.Ty a of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ® Replacement System ❑ Trealment,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 GAO:Fy losd28 <br /> —JG— 'l8 <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(gpelsf) 650 650 97.00' <br /> 0.7 <br /> V1.Tank Info Capacity in <br /> Gallons Total #of Manufacturer o <br /> New Tanks Existing Tanks Gallons Units °' n <br /> a U h y rn v. C7 C. <br /> Septic or Holding Tank 1000 990 1000 1 Wieser Z ❑ ❑ ❑ ❑ <br /> Dosing Chamber 600 600 1 Wieser ® ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) mb 's S' re MP.!MPRS Number Business Phone Number <br /> Daniels Plumbing&HeatingInc 007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 24056 State Rd 35/P.O. Box 326,Siren,WI 54872 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disappmvcd Permit Fee Date Issued Issuing Agent Signature <br /> El Owner Given Reason for Denial S J 7`S' S ofg a f 7 <br /> IX.Conditions of Approval/Reasons for Disappro al 2 2 np�q <br /> /1/ Gl/oGG S ow.✓ ow //v ZZ.t EC EN <br /> V <br /> D <br /> Attach to complete plans for the system and submit to the County only on paper not less thins In x 11 i rilsi <br /> SBD-6398(R03/14) BURNETT COUNTY <br /> ZONING <br />