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Department of Safety county BURNETT <br /> & Professional Set-Aces, <br /> Sanitary��t Number(to be filled in by Co.) <br /> Industry Services Division `Q <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-052400023-M <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 27640 HILL ROAD <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name - - - - - <br /> CY2w Capi-�-aA LI.G Parcel# <br /> 25-5 <br /> 05-004-016000 I Slc1 <br /> Property Owner's Mailing Address n/� e L�, ,e <br /> 2�� Govt.Lot 4 <br /> City,State I W'' ^, Zip Code Phone Number <br /> t Rum, rw 1 V �� —yam /4, Section 25 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 14 ,X. W <br /> EX or 2 Family Dwelling-Number of Bedrooms 8 3 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# NANA <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> V2,P113 SCOTT <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on fine A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A X Replacement System�w System p y Other Modification to Existing System El Additional Pretreatment Unit(explain) <br /> (explain) adding to existing <br /> B. ❑ HoldingTank In-Ground ❑At-Grade <br /> ❑ Individual Site Design El Other Type(explain) <br /> (conventional) XMound <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber List Previous Permit Number and Date Issued <br /> g ❑ Transfer to New Owner <br /> Expiration <br /> 362737/1999 <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil^pplication Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 0_ G 0 600 780 95.86 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o d <br /> New Tanks Existing Tanks y Y p <br /> o <br /> a U in rn s C7 A, <br /> Septic or Holding Tank 1000 1250 250 3 WIESER <br /> Dosing Chamber 1645 1645 1 WIESER X <br /> V.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI is Signature MP/MPRS Number Business Phone Number <br /> RYAN TRAND 798301 715-558-1673 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 10571N TOWN INDUSTRIAL PARK ROAD, HAYWARD, WI 54843 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee ;71 <br /> sued Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $��`��- 7 f, <br /> Conditions of Approval/Reasons for Disapproval <br /> Mt <br /> 1f aU k*ati S <br /> FOVC+N aU (,OU n fy and S 7kak ree-U*ExtS4h*. mu day --(o be rtf laud �-lh Cow As-am c� v t� <br /> 3 qM <br /> 504,NA -t'o lae.. I1lSpfG,4ed• POSS1.b1y rulace san t- <br /> d 1� S- U�t�s CLV-e- q) 13 2 t <br /> n I,1 (n 1��„p� Arch to complete plans for the system and submit to the County only on paper not less than 8 12 x I ' <br /> %UkrrCn{- 1 "( r Burnett County <br /> D-6398(R.0 /22 �� Land Services Department <br />