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o�""TMtvr County <br /> P Industry Services Division <br /> vi 1400 E Washington Ave Sanitary Permit Number(to be Slled in by o. <br /> P.O. Box 7162 <br /> 'a Madison,WI 53707-7162 <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 Z 73719 7 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted w <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 l m,Stars. RANrF f TNF RD GRANTSBURG 54840 <br /> I. Application Information-Please Print All Information Q S 7,Z <br /> Pronerty Owner's Name n rr ,,JJ Parcel# <br /> RObefT � L0.`\ Srni��, 07-034-2-37-18-30-302-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> 20528 RANGE LINE RD GRANTSBURG 54840 <br /> Govt.Lot I <br /> City,State Zip Code Phone Number NW%4,SW 1/4, Section 30 <br /> GRANTSBURG,WI 54840 715488-2618 (circle one) <br /> T37N; R18WEorW <br /> 11.Type of Building(check all that apply) Lot# <br /> ® I or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> [I City of <br /> ❑State Owned-Describe Use <br /> rc <br /> SM Number El Village of <br /> ® Town of TRADE LAKE <br /> III.Type of Permit: (Cheek 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.DispersaVIrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 450 455 95.0 <br /> 1.0 <br /> VL Tank Info Capacity in <br /> GallonsTotal #of °v <br /> Gallons Units Manufacturer c Tpp :, $, <br /> New Tanks Existing Tanks k'U � y y i,,,3 p, <br /> Septic or Holding Tank 1000 1000 1 WIESER CONCRETE INC. ® El ❑ ❑ ❑ <br /> Dosing Chamber 600 600 1 WIESER CONCRETE INC. ® ❑ ❑ ❑ ❑ <br /> VII,Responsibility Statement- I,the undersigned,�Xsli'mqfesponsibilily for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu er s MP/MPRS Number Business Phone Number <br /> CORY JACKSON 824339 715-566-2786 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 BLACK BROOK RD. WEBSTER,WI 54893 <br /> III.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee 00 Date Issued Issuing Agent Sign re <br /> ?7-6-. <br /> El Owner Given Reason for Denial $ l /-/' <br /> DL Conditions of Approval/Reasons for Disapproval <br /> "ECEIVE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t!t s 1 I r1la <br /> s <br /> BURNETT COUNTY <br /> SBD-6398(R03/14) ZONING <br />