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s, naxu:sAr County <br /> Industry Services Division <br /> 4822 Madison Yards Way Burnett <br /> Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> t w1 P.O.Box 7302 -7vA <br /> Madison,WI 53707 6��7✓� <br /> T4.S.K1\).Ai <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 mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary �+,,,„,� 2 !„ �' 1 3� <br /> purposes m accordance with the Privacy Law,s 15.04(1)(m),Stats same JGU 0 <br /> 3.Ap lieatloaa l kmation--Please Priat All Informatioe '51 f e-n <br /> Property Owner's Name Parcel# <br /> Ron Johnson 07-006-2-38-17-21-5 05-003-016000 <br /> Property Owner's Mailing Address Property Location <br /> 946 Daniels 70 Govt.Lot 3 <br /> City,I the' Zip Code Phone Number <br /> Siren WI 544872 612-760-4334 Section 21 <br /> H.Type of Building(cheek all that apply) Lot# T 38 N R 17 E � <br /> F/II or 2 Family Dwelling—Number of Bedrooms 3 2 Subdivision Name <br /> Block# Na <br /> ❑Public/Commercial—Describe Use <br /> Na ❑pity of <br /> ❑State Owned—Describe Use CSM Number I lVillage of <br /> CSM Vol. 18 Pg. 116 ❑✓Town of Daniels <br /> III.Type of POVVTS Permit:(Check either"Nero"or KResplacemvnf"and other applicable on line A. Check one boa on line B.Complete line C if <br /> applicable.) <br /> A. ❑New System []Replacement System ❑Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> ❑—1 B' Holding Tank []Replacement <br /> at-Grade ❑Mound Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑Renewal Before ❑Revision hange of Plumber ❑Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> 'rsaTFtt*tment'Ares and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 450 Na Na Na Na <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units D c <br /> New Tanks Existing Tanks o <br /> a U ✓ rn <br /> Septic or Holding Tank 3000 Na 3000 1 Wieser Concrete ✓ <br /> Dosing Chamber ❑ ❑ ❑ <br /> V.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POW'TS shown on the attached plan&; <br /> Plumber's Name(Print) Plumber's_$ignatu. MP/MPRS Number Business Phone Number <br /> Luke Schmitz ,. 884121 1715-468-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O. Box # 160 Shell Lake WI 54871 <br /> vt CountylDepartment Use Only <br /> Approved ❑Disapproved Permit Fee Date IssuedIssuing A ent Signature <br /> ❑Owner Given Reason for Denial 5 f LL <br /> Conditions of Approval/Reasons <br /> ff fopr-Disapproval <br /> CJ� <br /> �CIEWE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x I I inches <br /> SBD-6398(R.02/22) Burnett County <br /> Land Services De artment <br />