Laserfiche WebLink
Industry Services Division County <br /> 4822 Madison Yards Way Burnett <br /> Uf Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> = P.O.Box 7302 JTtN-22_193 <br /> Madison,WI 53707 040836 <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.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 /> DALE M STELLRECHT JR 07-024-2-39-14-26-3 02-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> 25372 ROLLING GREEN RD Govt.Lot <br /> City,State Zip Code Phone Number <br /> SPOONER WI 54801 715-635-4925 NW %,SW %, Section 26 <br /> II.Type of Building(check all that apply) Lot# T39 N R 14 E or W <br /> Di or 2 Family Dwelling—Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> [Public/Commercial—Describe Use <br /> lCity of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> :Town of Rusk <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 /> ` . ew System J Re lacement System they Modification to ExistingSystem(explain) Pretreatment Unit(explain) <br /> ❑N Y� I✓ P Y Y ( P ) DAdditionall P ) <br /> B. Holding Tank I1In-Ground Dt-Grade Mound ❑Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑Renewal Before ❑Revision Change of Plumber Dfransfer 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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 .7 642.8 652 94.5 <br /> Capacity in Total #of Manufacturer <br /> :3 <br /> Tank Information Gallons Gallons Units I' o <br /> • <br /> New Tanks Existing Tanks 0. <br /> ' <br /> n U in rn w C7 <br /> Septic or Holding Tank X 1 000 1 Wieser V �. <br /> Dosing Chamber I—"1 <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 ' MP/MPRS Number Business Phone Number <br /> Luke Schmitz 884121 715-520-2434 <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 Is i A nt Signa <br /> iigt\Approved ❑Disapproved $375' V l/6I,� <br /> ❑Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <br /> c51E4k $ 7jr <br /> 05.ec ina5+- � e 5?eel I D ECEGVE:n <br /> AUG 10 2022 Li <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 in i cc <br /> • <br /> SBD-6398(R.02/22) Burnett County <br /> Land Services Department <br />