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oomfnafce.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> trvepwimem <br /> n s n Madison,WI 53707-7162 Sanitary Perniit Number(to be filled in by Co.) <br /> 48 55 7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this forth to the appropriate governmental —�- <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Addr9ss(if different than raailingaddress) (� 1 <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Y <br /> purposes in accordance with the PrivacyLaw,s. 15.0 1 m,Stats. /� 1� <br /> L Application Information-Please Print All Information 8 as e Y stn raj <br /> Property Owner's Name Parcel# <br /> John Andrews O�y jrG 3G oa <br /> Property Owner's Mailing Address Property"hon <br /> Palmer Lane <br /> Govt.Lot ; <br /> City,State Zip Code Phone Number '/4 yy Section la <br /> Spooner Wi.. 54801 (circle one) <br /> IL Type of Building(check all that apply) Lot# T 39 N; R i W <br /> ®1 or 2 Family Dwelling-Number of Bedrooms 3 131, <br /> Subdivision I farne <br /> ❑PubliclCommercial-Describe Use Block# 151 <br /> ❑ City of <br /> i <br /> ❑ State Owned-Describe Use CSM Number ❑ VillageI IR of <br /> Town o$ <br /> IfL Type of Permit: (Check only one box on tine A. Complete line B if applicable)A. New System El Replacement n Treatment/Holding Tank Replacement Only ❑ Other M c ification to Existing System(explain) <br /> System <br /> -ErB. Permit Permit Revision LJ Change of ❑Permit Transfer to Lin Previous ermit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV.Type of POWTS stem/Com onent/Device: Check ati that a I <br /> Non-Pressurized In-Ground Pressurized In-Ground At-Grade Mound>24 N.of suitable soil Mo d 124 in.of suitable soil <br /> ❑ Holding Tank ❑ Other Dispersal Component(exphtin) ❑Pretreatment Device(explain) <br /> i <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(s System Elevation <br /> 450 r 99 C' <br /> VL Tank Info Capacity in Total #of Manufacturer w <br /> Gallons Gallons Units o <br /> New Tanks Existi Tanks w ] .a < <br /> Septic or Holding Tank 1000 1000 1 Wieser ® ❑ 1:1Dosing ch®nber 600 1600 1 Wieser ® F-1 -= ❑ ❑ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the sail whed plana. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Numb Business Phone Number <br /> Richard O'Hare 225920 715-634-8176 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 14346W St.Rd. 77 Hayward Wi. 54843 <br /> VIIL Court /De artment Use Only <br /> Approved _ Disapproved Permit Fee Date Issued is Signature <br /> _Owner Given Reason for Denial $ <br /> 1u/p.✓] y Ly 0.� <br /> 7 V JU <br /> IX Conditions of ApprovalMeasons for Disapproval <br /> Attach to complete plans for the system and smbmR to the County only on paper not lee,than 8 In z I I inches in size <br />