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osr✓ qT County <br /> 4r Industry Services Division BURNETT <br /> ' �A. = 1400 E Washington Ave <br /> s ¢' : Sanitary Permit Number(to be filled in by Co.) <br /> y P.O. Box 7162 I <br /> 'a Madison,WI 53707-7162 <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. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel 4 <br /> DONALD W&BONITA M OLSON 07-016-2-39-17-27-3 02-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> 9367 COUNTY RD.D <br /> Govt.Lot <br /> City,State Zip Code Phone Number N W%4,SW V4, Section 27 <br /> WEBSTER,WI 54893 715-866-7432 (circle one) <br /> T39N; R17WEorW <br /> II.Type of Building(check all that apply) Lot 9 <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block 4 <br /> El City of <br /> El State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> ® Town of LINCOLN <br /> III.Type of Permit: Check only one bog on line 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 System/ omonent/Device: 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.Dis ersaVlreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required Is Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 750 750 93.5' <br /> .6 <br /> VI.Tank Info Capacity in <br /> Gallons Total 4 of <br /> Gallons Units Manufacturer G ;, <br /> New Tanks Existing Tanks U yr rn k.Q 0. <br /> Septic or Holding Tank 1000 1000 1 ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersign assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI her's Signature MP/MPRS Number Business Phone Number <br /> NELS KOERPER 225229 715-866-8608 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7845 COUNTY RD.D WEBSTER,WI 54893 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Signature <br /> El Owner Given Reason for Denial <br /> DL Conditions of Approval/Reasons for Disapproval InOCT <br /> ECEIVE <br /> 21 2015 t1D <br /> Attach to complete plans for the system and submit to the County only on paper not lens than a r/2 z ach 'n— <br /> BURNETT COUP <br /> ZONINQ. <br /> SBD-6398(1103/14) <br />