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Industry Services Division County <br /> �1 ) 4822 Madison Yards Way Burnett <br /> : Madison,WI 53705 Sanitary Permit Number to be filled in by Co.) <br /> P.O.Box 7302 -23-24 / <br /> Madison,WI 53707 �a ��(O g 33 <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 Project Address(if different than trailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04(1)(m),Slats. Same <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# -Tax l 5 3 <br /> Kyle Vanderhoof 07-008-2-38-14-06-4 04-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> 3070 Oak Rd. Govt.Lot <br /> City,State Zip Code Phone Number <br /> Shell Lake WI �54871 715-419-0610 SE ,,,,SE V., Section 6 <br /> II.Type of Building(check all that apply) Lot a 1-38 N R 14 E 6) <br /> PIT or2 Family Dwelling—Number of Bedrooms Na Subdivision Name <br /> 2 Block# Na <br /> aublic/Commercial—Describe Use <br /> Na ❑City of <br /> ❑State Owned—Describe Use CSM Number illage of <br /> Na ❑✓Town of Dewey <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> ❑✓ Kew System []Replacement System ❑Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> ioldin g B' ❑1 �Tank In-Ground at-Grade :Mound Individual Site Design Other Type(explain) <br /> (conventional) <br /> C• ❑Renewal Before ❑Revision hange of Plumber ❑transfer to New Owner ist Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd'sf) Dispersal Area Required(sty Dispersal Area Proposed(sf) System Elevation <br /> 300 .7 429 Eisa of 450 93.60 ft. <br /> Capacity in 'total #of Manufacturer <br /> Tank Information Gallons Gallons Units + o o <br /> New Tank. Existing Tanks o d ro <br /> Septic or Holding Tank 750 750 1 Wieser Concrete ✓ <br /> Dosing Chamber ❑ <br /> V.Responsibilih Statement-I,the undersigned,assume resp <br /> ,pnsibfljtv for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sig turc MPiMPRS Number Business Phone dumber <br /> Luke Thoresen 1037348 1715-463-3499 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 330 Industrial Ave. ( P.O. Box 705) Grantsburg WI 54840 <br /> VI.CounhlDepartment Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issuin Agent Signature <br /> ❑Owner Given Reason for Denial $ f I zv—S <br /> Conditions of Approval/Reasons for Disapproval <br /> Mt-t4 ail X4xi(�-3 <br /> 0 <br /> 5+��{e m �o bt S,e rv�c -emery 3 cars Lrl :O'� 1 � 2 . <br /> Attach to complele plans for the system and submit to the County only on paper not less than S 1!2 x 11 nches in size Burnett County <br /> Land Services Department <br /> SBD-6398(R.02122) M �`� loce(v <br />