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County <br /> Industry Services Division Burnett <br /> s 1400 E Washington Ave Sanitary Permit Number(to be filled in b P P.O. Box 7162 q s>?'OS Co.)(940 i7 <br /> 1,, $ Madison,WI 53707-7162v <br /> C5T-A2 -05 <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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 1175 Popple Rd a-,6 382, <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Mark Rosenow 024313601200 <br /> Property Owner's Mailing Address Property Location <br /> 12330 W Hildreth Rd <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW'/.,NE'A, Section 36 <br /> Hayward,WI 54843 (circle one) <br /> T39N ; R14EorW <br /> 11.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> 0 City of <br /> ❑State Owned-Describe Use 0 Village of <br /> CSM Number <br /> ® Town of Rusk <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ®New System 0 Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ®Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 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 /> 450 Rate(gpdsf) 643 652 90-97 <br /> .7 <br /> VI.Tank Info Capacity in 0.1 <br /> Gallons of# -' U <br /> T tiotal ° o'v <br /> Manufacturer <br /> Gallons Units 5 c 2 e 8 2 3. .5 <br /> New Tanks Existing Tanks 4 U in ., v) 'ram. t7 o.. <br /> Septic or Holding Tank 1000 1000 1 Wieser ® 0 ODD <br /> Dosing Chamber 0 0 0 0 0 <br /> VII.Responsibility Statement- I,the undersigned,assume respon ' ility for' stallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Dan Burch 253808 715.416.1642 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1118N Front Street Spooner WI 54801 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Pelee. Date Issued Is ing ent Sig. atu j/ <br /> ❑Owner Given Reason for Denial $ P13 <br /> IX.Conditions of Approval/Reasons for Disannroval /, - 9 . 3 <br /> .., D ECEOVE ; <br /> Mc, Oz.5 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 c I i "es in jAN 2 8 hilt . _) <br /> SBD-6398(R03/14) Burnett County <br /> Land Services Department <br />