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Department of Safety County <br /> & Professional Services, BURNETT <br /> /- Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division <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 PWTS-052300753-C <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. (SAME) <br /> 1.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> JEFFREY A. & PATRICIA J. OLSON 07-034-2-37-18-04-4 01-000-011000 <br /> Property Owner's Mailing Address Property Location UC f <br /> 11840 M Y ROAD Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> FREDERIC, WI 54837 NE %<, SE '/<, Section 04 <br /> II.Type of Building(check all that apply) Lot# T 37 N R 18 J�Xw <br /> EX or 2 Family Dwelling-Number of Bedrooms <br /> 3 NA Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial-Describe Use <br /> NA ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA EXown of TRADE LAKE <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 /> A. <br /> L New System IlReplacement System [J Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B' ❑ HoldingTank ❑ At-Grade L9 Mound ❑ Individual Site Design ❑ Other Type(explain) <br /> in ground g yP ( p ) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration 620624/ <br /> IV.Dispersal/Treatment Area and Tank Information: _ <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 2.0 225 325 100.83 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o T <br /> New Tanks Existing Tanks e d <br /> 0 <br /> r: U rn y rn i <br /> Septic or Holding Tank 1000 _ 1000 1 WIESER X _ <br /> Dosing Chamber 650 650 <br /> V.Responsibility Statement- I,the undersigned,assu a 'ponsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI er' nature MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 24884 S.T.H. 35, SIREN, WI 5487 <br /> VL County/Department Use Only <br /> Approved ❑Disapproved Permi <br /> t F,eee� Date Issued Issuing ent VS naattu-re <br /> ❑Owner Given Reason for Denial 5✓/ ✓ <br /> Conditions of Approval/Reasons for Disapproval <br /> rn ee-�- i ll t %de ;reme n f S <br /> D <br /> ECEME <br /> MAY 11 2023 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I inches rn s' Urnett County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />