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rcom-Tiko,ti> Industry Services Division County <br /> 'I `; 4822 Madison Yards Way 53705 Burnett <br /> s • =a PO Box 7162 Sanitary Permit Number(to be filled in by Co)) <br /> ,=l� _ ,� Madison,WI 53705-7162 SAM a( 3a s (o 1-10‘62. <br /> kb'f.45tt NPLI <br /> 0 g7 1/ -460 <br /> Sanitary Permit Application State Plan Review Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit PWTS— -C <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 Servies.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),Stats. 25851 Beaver dam road <br /> I. Application Information—Please Print All Information \‘,0 ?:) <br /> Property Owner's Name Parcel# <br /> LJ Webster 024311901300 <br /> Property Owner's Mailing Address Property Location <br /> 469 Troon Court <br /> City,State Zip Code Phone Number Govt.Lot <br /> Hudson WI 54016 715-505-0941 se 1/4, ne '/, Section_19 <br /> (circle one) <br /> II.Type of Building(check all that apply) Lot# T 39 N; R 14 E or5 <br /> X 1 or 2 Family Dwelling—Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> X Town of <br /> Rusk <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System X Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> ) <br /> B. <br /> U .Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> X 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 Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 6300 30O? .7 428 452 92.8 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks t o y Y a i <br /> a U .65 y w 3 a, <br /> Septic or Holding Tank X 750 1 Weiser x <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber'$fgn.•,• MP/MPRS Number Business Phone Number <br /> `� 884121 715-520-2434 <br /> Luke Schmitz <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 160 Shell Lake WI 54871 <br /> VI .County/Department Use Only <br /> Permit Fee Date Issued I if•• •lent Si, atu <br /> _ <br /> Approved ❑ Disapproved II/0^� 111111111111111' <br /> II Owner Given Reason for Denial $ LI-25 <br /> ''l 1 r d '1.. !I/ ��..- <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> K 53�i ____¶ <br /> EllvEll <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 rn TTI j es iu sib <br /> Li l 77 201 j <br /> SBD-6398(R.04/19) Burnett County <br /> Land Services Department <br />