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0. "' --• Department of Safety County <br /> �4 Burnett <br /> i \= &Professional Services, <br /> S. I< S itary Permit Number11to be filled in by Co.) <br /> `_ ./ Industry Services Division -,2 _ 2,z 7 <br /> G57 - 22 - L1"7 <br /> Sanita Permit An lication State Transaction Number <br /> Application PWTS-092202203-C <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. 1732 Sleepy Hollow Rd. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Juris Plesums 07-024-2-39-14-35-2-03-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> 1732 Sleepy Hollow Rd. <br /> Govt.Lot <br /> City,State Zip Code Phone Number <br /> Spooner WI 54801 SW '/., NW '/<, 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 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> XTown 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. <br /> ❑New System Aleplacement System 0 Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B. <br /> ❑ Holding Tank ❑ In-Ground ❑At-Grade AMound ❑ Individual Site Design ❑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(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 1.0 450 450 99.4 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units 2 o b o <br /> New Tanks Existing Tanks `w° o c y = 13 _8 2 2 <br /> a. U rn y cn i=.3 F. <br /> Septic or Holding Tank 1000 1600 1 Wieser X ' <br /> Dosing Chamber 600 <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 SignatiIre A fP/MPRS Number Business Phone Number <br /> Rick Brown L 231251 715-419-0739 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 637 Spooner WI 54868 <br /> Silk i <br /> VI.County/Department Use Only <br /> Permit Fee r Date Issued 1 Iss ent nature <br /> l(pproved 0 Disapproved <br /> ❑Owner Given Reason for Denial '14�5— 9 1 a �i <br /> Conditions of Approval/Reasons for Disapproval <br /> mee+ 2 cof cr I,''c.. %417c or 1013 rh. + be 60476'-cc, <br /> wr- a Cerf !✓ my. <br /> 114.042a sq�4mee- "(i ofi 9e 044- sf4e • '& ECE0wk) <br /> �weeeL i i /11aAC(i4 I Q-ht4x c nits c 1"0P Attach to complete plans for the system and submit to the County o ly on paper not less than 8 1/2x 11 iize SEP /1 <br /> 19 2022 <br /> SBD-6398(R.03/22) <br /> Burnett County <br /> Land Services Department <br />