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t7,, -;4v- j County <br /> ,.--i4s <br /> J/�'j" "Ni,, Industry Services Division Burnett <br /> 1. 1400 E Washington Ave _ <br /> ;s Sanitary Permit Number(to be filled <br /> * P.O.Box 7162 j+ <br /> /0 Madison,WI 53707-7162 <br /> �ssrt7NnL, 4,r1 ',.- 1 5g <br /> Sanitary Permit Application State Transaction Number- <br /> in:t;;ccrdanc th 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 I Project Address(if different than mailing address) i <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. 4730 Bertram Rd. <br /> . I. Application Information 7 Please Print All information i_—._.._ <br /> Property Owner's Name Parcel 4 <br /> Jeff and Gayle Sprinkel 07-014-2-3845-09-5 05-006-018000 <br /> Property Owner's Mailing Address j Property Location <br /> 2636 I G°i Ave.South <br /> —._-- ; Govt.Lot 5+6 <br /> City,nta.c Zip Code Phone Number tn, /+, Section 9 <br /> M nreapoii MN 55407 612-202-1554 {cle one; <br /> _. . T38N : R15EofW�i t' <br /> U.Type€pe of Building(check all that apply) Lot H <br /> 2, i tr 2 1:,unity Dwelling—Number of Bedrooms 3 2 Subdivision Name <br /> _ Na <br /> I.— PublicK:ortmercial—Describe Use Block 4 <br /> . Na <br /> i D City of <br /> Slate.:..Owned..,Describe Use <br /> _.. <br /> CSM Number ❑ Village of <br /> Vol. 13 Page 138 . ►. Town of LaFollette <br /> '1'__ ..__i (._.._. _ = A. Consstlete line B if applicable) <br /> ,- z tTo i t'et~trti, (Check one box on line <br /> i ❑NQ'ti System E Replacement System i ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing S,, m; .. <br /> k..3,. ! ❑ Permit Renewal % ❑ Permit Revision El Change of I ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> 1+- Tvrne of POWTS SvstorniCom onent'Device: (Check all that ajply) <br /> Z Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ill 1=.oid:ns!,Tank Ei Other Dispersal Component(explain) Lift ❑Pretreatment Device(explain) <br /> • V.iv ts_persai€/T'r eatmeitt Area Information: <br /> Design Flow(gpd) ! Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 i Rate(epdsi) 643 : Eisa of 660 C-I.=100.30 C-2=100.00' <br /> { ., C-3=99.56' <br /> V i,.'ank 4fe Capacity in <br /> Gallons B ° v <br /> Total Hof ' ° <br /> Manufacturer t '..cc b o <br /> Gallons Units 1 B o Y y 3 <br /> r.vPattks Existing Tanks c.U b <br /> Septic or Holding Tank 1000 ! 1000 1 1 Wieser Concrete 1 ►� ❑ <br /> : Dosing Chamber 600 _600 I Combination .-.i.0.._-.I E:. ° ❑ E <br /> VII.f espo Isibility Statement 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plur.the- .Naze(Print) I Pj umb, --'•.rr:utnure MP/MPRS Number • Business Phone Number <br /> ::.. !' " w--"% 884121 715-468-2434 <br /> Plumbers Address(Street,City,State,Zip Coder ....... <br /> — <br /> P.ti.Box 160 Shell Lake W1 54871 <br /> VIII.Count}department Use Only <br /> l <br /> Ant roved ❑ <br /> 1 Disapproved 1 Permit Pee Date Issued .1¢s'uinc„Agent Signature <br /> 0.Owner Given Reason tar Denial <br /> 1X,Curidk`ions of Approval/Reasons for Disapproval <br /> tZ <br /> l ' <br /> Attach to complete plans for the system and submit to the County only on paper not less than S 112 x I cb n size <br /> nine i �+ <br /> SBD-6398(R03/14) . .16j� `�7 i <br /> ��` �11i i74ti'� v <br /> !..card'Srui.CesS Dez.. <br />