Laserfiche WebLink
/,s""-740"yl County <br /> r � ``` Industry Services Division Burnett/ 1400 E Washington Ave <br /> 1 P.O. BOX 7162 Sanitary Permit Num r(to be filled in by Co.) <br /> Madison,WI 53707-7162 544 <br /> Sanitary Permit Application State Transactio//q/�Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit GOvvf f Z view <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <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 1 (m),Slats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Paul Kipping 07-028-2-40-14-11-5-05-005-012000 <br /> Property Owner's Mailing Address Property Location <br /> 29001 Mckenzie Rd <br /> Govt.Lot 5 <br /> City,State Zip Code Phone Number /4, /., Section 11 <br /> Spooner,Wi. 54801 715 635-8692 (circle one) <br /> T40N R 14E��Vi <br /> H.Type of Building(check all that apply) Lot# <br /> ® l or 2 Family Dwelling—Number of Bedrooms 21 Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# <br /> ❑State Owned—Describe Use ❑ City of <br /> rcys, <br /> M Number ❑ Village of <br /> 0 P26 ® Town of Scott <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System ❑ Treatment/Holding. Re <br /> 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 301 /_qS I' <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> 1 KK,�� <br /> ❑ Non-Pressurized ound ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil Mound<24 in.of suitable soil <br /> ❑ Holding Tank Kqfter Dispersal Component(explain) add 320 gallon pump tank ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Rate(gpdsf) <br /> VI.Tank Info Capacity in <br /> Gallons Total #of <br /> B <br /> 0 <br /> Manufacturer $ U v U <br /> Gallons Units o g ' 0 <br /> New Tanks Existing Tanks ct U in is V L1. <br /> Septic or Holding Tank 320 320 1 Wieser ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb Signature MP/MPRS Number Business Phone Number <br /> Gary Christman 248704 7154160373 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> N 100 15 Mack Lake Road Trego WL 54888 <br /> VIII.County/De artment Use Only <br /> [� Approved ❑ Disapproved Permit Fee 0 O Date Issued Issuing Agent Sign e <br /> 'A\ // <br /> ❑ Owner Given Reason for Denial $ 373� AQ`�T <br /> IX.Conditions of Approval/Reasons for Disapproval D EC E 1:/ E <br /> OCT 13 2016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inc i <br /> BURNETT COUNTY <br /> SBD-6398(R03/14) ZONING <br />