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pa*AflT1<Cy� County <br /> t �I ` Industry Services Division BURNETT <br /> 1400 E Washington Ave <br /> P P.O. Box 7162 Sanitary P Number(to be filled in by Co.) <br /> _ - j� �- I <br /> it <br /> ^ys Madison,WI 53707-7162 S914-<Us ' <br /> Sanitary Permit Application State Transaction Number <br /> in accordance with SPS 383.21(2),Wis. Aden Code,submission of this form to the appropriate governmental unit <br /> is required prior to obtaining a sanitary permit. Note:Application forms for statcrowned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may he used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15 A 1 m Stats. 4646 LAKE 26 ROAD <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> MIKE MASTERJOHN 07-032-2.41-15-22-5 05-002-0I3000 TAX#21527 <br /> Property Owner's Mailing Address Property Location <br /> P.O.BOX 144 <br /> Govt.Lot N200'E200'OF S70W OF EI/2 GL2 <br /> City,State Zip Code Phone Number '%:, ''/,, Section 22 <br /> SPOONER,WI 54801 715 4914543 (circle one) <br /> T41N R15WEorW <br /> IL Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms Z' Subdivision Name <br /> ❑Public/Commercial-Describe Use Block 4 <br /> City of <br /> ❑State Owned—Describe Use <br /> CSM Number ❑ Village of <br /> .92 ACRES ® Town of SWISS <br /> III.Type of Permit: Check only one bog on fine A. Complete line B if applicable) <br /> A. ❑ New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. Type of POWTS S stem/Com nent/13m ice: (Check all that apply) <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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 Rate(gpdsf) 429 450 <br /> .7 <br /> VL Tank Info Capacity in <br /> ^3 e o <br /> Gallons Total 4 of Gallons Units Manufacturer <br /> ew <br /> N Tanks Existing Tanks <br /> Septic or Holding Tank 800 800 SKAW ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ El <br /> VIL Responsibility Statement- I,the undersigned,assume responsibility for lation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim) MaK SEPTIC p piwnberrsi3IUW MP/MPRS Number Business Phone Number <br /> Mel FeT on dba R SEPTIC U at I 'Air- l l UIY �)",Ail A MPRS 224879 <br /> Plumber's Address(Street, 1 y '1a■I 518'01 � <br /> - 35-7482 <br /> VAn Court /De artment Use Only <br /> t7c <br /> ved ❑ Disapproved Permit Fee D Date Issued y Issuing Agent <br /> ❑ Owner Given Reason for Denial is 3 7S 7-/a / rXE <br /> C <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> JUN 12 2017 IU <br /> BURNETT COUNTY <br /> Attach incomplete plans far the system and submit to the County only on paper not less than 8 112111 inches in <br />