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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> is c o n s i n Madison,W l 53707-7162 Sanitary Permit Number(to be filled in by Co J <br /> Department of Commerce <br /> Sanitary Permit Application StateTransaction Number <br /> In accordance with s.Comm.83 2](2),Wis,Adm.Code,submission of this form to the appropriate governmental koleco <br /> unit is required prior to obtaining a sanitary, permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Priva Law,s. 15.041 m),$tats. 27075 W Benoit Lake Rd. <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel N oz y-310 -a-4 cw(Z73 <br /> Betty Leef 07-024-2-39-14-04-104-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> 2135 Acorn Rd. Govt.Lot <br /> City,State Zip Code Phone Number <br /> SE y, NE Y,, Section 4 <br /> Webster WI 54893 (circle one) <br /> Il.Type of Building(check all that apply) Lot k T 39 N; R 14 E m W <br /> Q1+or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block k <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> Town of Rusk <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New S stem <br /> y ❑ Replacement System ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit RevisionList Previous Permit Number and Date Issued <br /> ❑Change of Plumber 11 Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that a 1 <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaVrmatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 0.7 429 430 97.0 <br /> VI.Tank Info Capacity in Total q of Manufacturer <br /> Gallons Gallons Units s o$ <br /> New Tanks Existing Tanks u c u <br /> d U rn w cO <br /> Septic or Holding Tank 7550 7550 t Wieser 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's Signature MP/MPRS Number Business Phone Number <br /> Willie Kauffman a31g 715-766-3493 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W1949 CTH HWY E Springbrook WI 54875 <br /> VII .Coun /De artment Use Out <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing A n gnature <br /> ❑ Owner Given Reason for Denial ',525_'14Z 27,r4te r�2 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> nn 5;(rn9;0VE <br /> Attach to complete plans for the system and submit no the County only on paper not has than 8 in rhes m stu <br /> JUN 2 7 2012 <br /> SBD-6398(R.02/09)Valid thru 02/11 BURNER COUNTY <br /> ZONING <br />