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„,_":`1 , Industry Services Division County Burnett <br /> 4822 Madison Yards Way <br /> ;.. • - Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> '$ P.O. Box 7302 3 P- - `�' ,9 <br /> '',x, ;a Madison,WI 5302 CS7-- ° .'/_c� 3�� <br /> Sanitary Permit Application State Transaction Number £�l <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 1551 Rooney Lake Rd <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# 028411401500 <br /> Steve Listle <br /> Property Owner's Mailing Address Property Location <br /> PO Box 290 <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> Watertown WI 53094 <br /> NW Y,NE /, Section 14 <br /> It.Type of Building(check all that apply) Lot# T 40 N R 14 E ote <br /> it 1 or 2 Family Dwelling—Number ofBedrooms 1 Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# <br /> ❑City of <br /> ❑State Owned—Describe Use <br /> CSM Number 0 Village of <br /> filTown 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. New System ❑Replacement System ❑ Additional Pretreatment Unit <br /> y p y ❑Other Modification to Existing System(explain) (explain) <br /> B' ❑Holding Tank 'In-Ground ❑At-Grade g Type(explain) <br /> ❑ Mound ❑ Individual Site Design ❑Other <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(st) Dispersal Area Proposed(sf) System Elevation 95.5 <br /> 150 1.6 93.7 131.25 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units s 0 <br /> New Tanks Existing Tanks ` o u o : t: o <br /> a U tip j v: iZ E.7 E. <br /> Septic or Holding Tank 320 320 1 Wieser x <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assume respo bii' for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signat e MP/MPRS Number Business Phone Number <br /> Dan Burch 253808 715.416.1642 <br /> Plumber's Address(Street,City,State,Zip Code) N5921 County Hwy K Spooner WI 54801 <br /> VI.County/Department Use Only <br /> Permit Fee Date Issued Issuing Ag t Signa <br /> Approved 0 Disapproved <br /> pr G <br /> S qd5 p 5))3l a s �j� <br /> ❑Owner Given Reason for Denial !! <br /> Conditions ili tApproval/Rea$ons fo approval M <br /> JJe 1a JJI � ( 1 ECIEO l/ <br /> pe US& r t be cl.s 1o5ec 0."4" 45/ o� ;n3Qec.f'o4. D �_, <br /> IED <br /> I r � <br /> MAY 2 3 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 11 inc1b in.Burnett County <br /> Land Services Department <br /> SBD-6398(R.02/22) <br />