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Department of Safety County <br /> Burnett <br /> & Professional Services, <br /> _ _ anitary Permit Number(to be filled in by Co.) <br /> �_ Industr' Services Division5PlIQ <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. 24967 Trails End Rd. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Karl Plesums 024313502500 <br /> Property Owner's Mailing Address Property Location <br /> 24967 Trails End Rd. <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> Spooner WI 54801 SE ANE /., Section 35 <br /> II.Type of Building(check all that apply) Lot# T 39 N R 14 E or W <br /> or 2 Family Dwelling-Number of Bedrooms 4 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> A'own 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 /> A. y P SystemExisting System(explain) (explain) <br /> ❑New System lacement ❑ Other Modification to ❑Additional Pretreatment Unit <br /> B' ❑HoldingTank A-Ground ❑At-Grade <br /> ❑Mound ❑Individual Site Design ❑ Other Type(explain) <br /> (conventional) <br /> C. CIRenewal 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(sf) Dispersal Area Proposed(st) System Elevation <br /> 600 .5 1200 1213.2 95.0 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units v to <br /> New Tanks Existing Tanks c B 6 T3 2 ` <br /> U in y n rZ C7 P. <br /> Septic or Holding Tank 320 1000 1320 2 Wieser&Skaw 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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Rick Brown 231251 715-419-0739 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 637 Spooner WI 54868 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee ^12 Date Issued Iss ' g ge Signature <br /> ❑Owner Given Reason for Denial $ 4 v V 84)-,21 as <br /> Conditions of Approval/Reaso for Di pproval <br /> ��0.11 5 � I �� <S <br /> l e 05 �eu (a�1 <br /> 4--)Sal -�be y, �h' ® 5� , <br /> /n <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 I/2 x 1 net in sikUG 5 20•'2 / <br /> SBD-6398(R.03/22) - Burnett County <br /> Land Services Department <br />