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County <br /> Industry Services Division Bumen <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> Madison,WI 53707-7162 �5` <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 <br /> is required prior to obtaining a sanitary permit. Noce: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 Priyawy Law,s.15. 1 m),Stats. 30273 Eliot Johnson Rd <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Douglas Dorgan Life Eastatc 07-032-241-15-26-5 05-W2-021000 <br /> Property Owner's Mailing Address Property Location <br /> 726CRESTVIEW DR <br /> Govt.Lot 7, <br /> City,State Zip Code Phone Number 21/,, /4, Section 26 <br /> BOLINGBROOK,IL 60440 (circle ore) <br /> T41N15; RWEoW <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ® Town of Swiss <br /> III.Type of Permit: Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System 0 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 (honer <br /> IV.Type of POWTS S stem/Com onent/Device: (Check all that a 1 <br /> ®Nun-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) ❑Pr treatment 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 /> 750 Rate(gpdsf) 1071.4 low 92.5-87.51 <br /> .7 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of Manufacturer j y <br /> Gallons Units „ c ao 3 <br /> k ' <br /> New Tanks Existing Tanks Jn rn !a.V W <br /> Septic or Holding Tank x 1733 1 Wieser ® ❑ El 11 ❑ <br /> Dosing Chamber x 1085 1 Wieser 0 0 11 ❑ <br /> V11.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Planaber's Name(Print) s � MPAviPRS Number Business Phone Number <br /> Luke Schmitz 894121 715.468-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 160 Shell Lake W154871 <br /> II.Conn /De artment Use Onl <br /> Approved ❑ Disapproved Permit Fee 00 Date Issued Issuing Agent Signatu <br /> ❑6wner Given Reason for Denial S 37S ' 9-mo - 1-1 <br /> IX.Conditions of ApprovallReasons for Disapproval <br /> Pr--% ECEIVE <br /> Attach to complete plans for the system and submit to the Comity only on paper not less than 12 t in 'z1 C 2017 <br /> SBD-6398(I103/14) BURNETT COUNTY <br /> ZONING <br />