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^aTxevTo County <br /> y Industry Services Division BUNT <br /> 1400 E Washington Ave <br /> sr K Sanitary Permit Number(to be Shed in by Co.) <br /> > P.O. Box 7162 <br /> Madison,WI 53707-71628� � <br /> roH�t� <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this forth 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. 26426 BLUEBIRD TRL <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Carl Rachner 07-018-2-39-16-07-3 03-000-013000 <br /> Property Owner's Mailing Address Property Location <br /> P.0.Box 279 <br /> Govt.Lot <br /> City,State Zip Code Phone Number SW'/4,SW'/4, Section <br /> WEBSTER,WI 54893 (circle one) <br /> T39N; R16WEorW <br /> II.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 /> ❑State Owned-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ® Town of Meenon <br /> III.Type of Permit: Check only one box 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/Component/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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpds f) 643 643 97.0' <br /> .7 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of a ° _ <br /> Manufacturer <br /> fact <br /> Gallons Units 1! a a <br /> New Tanks Existing Tanks y U 'rn w C7 fl. <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete ® ❑ ❑ El El <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pluis Signature MP/MPRS Number Business Phone Number <br /> NELS KOERPER "'0 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 _ 0 Date Issued Issuing Agent Signator <br /> ❑ Owner Given Reason for Denial S 7 s' S 3 - <br /> IX.Conditions of Approval/Reasons for Disapproval ECEO VJxE <br /> MAY <br /> 1IA1IYVv�„1144-PP��3 2016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x l l i cs siu <br /> BURNETT COUNTY <br /> SBD-6398(R03/14) <br /> ZONING <br />