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`ytt,sxnrfv , County <br /> Safety and Buildings Division Burnett <br /> 201 W.Washington Ave., P.O. Box 7162 Sanitary P�Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 � _! <br /> _.Ar�75V1/1N0�hi�. <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),W is.Adm.Code,submission of this form to the appropriate governmental unit Project Address(if different than mailing address) <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 Servies. Personal information you provide may be used for secondary Same <br /> purposes in accordance with the Privacy Law,s. 15.04(I)(m),Slats. <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Brent and Rebecca Erickson 07-018-2-39-16-26-3 01-000-017000 <br /> Property Owner's Mailing Address Property Location <br /> 6416 Midtown Rd. <br /> Govt.Lot 2 <br /> City,State Zip Code Phone Number NEV., SW'/<, Section26 <br /> Siren WI 54872 651-248-8728 (circle one) <br /> Ill.Type of Building(check all that apply) Lot# I'39N; R 16 E of w / <br /> 1 or 2 Family Dwelling—Number of Bedrooms 3 Na Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Na ❑ Town of Meenon <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ®Replacement System Trea[ment/Holding'I'ank Replacement Only El Other Modification to Existing System(explain) <br /> ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B. Permit Renewal El Permit Revision El Change of Plumber <br /> Before Expiration Owner s a1r 9'�p • g0 <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ Al-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 Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 450 .7 643 EISA of 680 C-1 =99.30'C-2=99.25' <br /> V1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units D o U <br /> New Tanks Existing Tanks <br /> o <br /> Septic or Holding Tank 1000 A 1000 1 Wieser Concrete X <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,a e esponsibility for installation of the PORTS shown on the attached plans. <br /> Plumbers Name(Print) Plum r ature MP/MPRS Number Business Phone Number <br /> Cory Jackson // ' 824339 715-866-8944 <br /> Plumber's Address(Street,City,Slate,Zip Code) <br /> 9306 Black Brook Rd.Webster WI 54893 <br /> VII1.Count /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Fisueed issuing Agent Sign re <br /> ❑ Owner Given Reason for Denial <br /> ►X.Conditions of Approval/Reasons for Disapproval Eu E VE <br /> D <br /> AUG 1$ 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 11 inches in <br /> SBD- 6398(R. 11/11) BURNETT COUNTY <br /> ZONING <br />