Laserfiche WebLink
Industry Services Division County <br /> t's*/, '' 4822 Madison Yards Way U f 14 <br /> (sl '5' Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7302 �•f{ , Qa l Madison,WI 5302 / JU. <br /> �( <br /> State Transaction Number <br /> • Sanitary Permit Application <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.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Joanna Bartosh 34235 <br /> Property Owner's Mailing Address Property Location <br /> 27405 County Hwy H Govt.Lot <br /> City,State Zip Code Phone Number <br /> Webster WI 54893 SE Y4, NW 'A, Section 33 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 14 E o <br /> ;CI or 2 Family Dwelling—Number of Bedrooms 2 Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# <br /> 0 City of <br /> ❑State Owned—Describe Use <br /> CSM Number 0 Village of <br /> Town of Scott <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. y P SystemExisting System(explain) (explain) <br /> ❑New System a lacement ❑ Other Modification to ❑ Additional Pretreatment Unit <br /> B' ❑ HoldingGround ❑At-Grade ❑ Mound ❑ Individual Site Design <br /> Tank �- gn ❑ Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sl) Dispersal Area Proposed(st) System Elevation <br /> 300 .7 428 440 93 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units .o 2 a) <br /> • <br /> New Tanks Existing Tanks t o v <br /> o U n y r ii u. ( Li, <br /> Septic or Holding Tank Filter basin 750 750 1 Wieser x <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb 's Signature MP/MPRS Number Business Phone Number <br /> Kelly Ferguson � 224069 715-416-4597 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W9502 Dock Lake Road Spooner WI 54801 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved / <br /> Pr <br /> Permit Fee Date Issued Is • g ge t Signa <br /> 0 Owner Given Reason for Denial $ 375 I[/1?-1 ` ?-0) <br /> /44/ <br /> Conditions of Approv l/Reasons for <br /> �Di pproval / (� n �f <br /> e� 1( 5e'1 CMG s . t �.t r/j,�p�L � C L� U l/ <br /> ED <br /> (1)1 (3 JXg �/►'t,�51. tot ect ei ��' ( D C►t 7l0`I 4¢37.' <br /> JUN 1 7 2022 <br /> Burnett County <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 xlaaeltitrafIcas uepartment <br /> SBD-6398(R.02/22) <br />