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p <br /> nsvxarvap Cowry <br /> _ zF % Safety and Buildings Division Burnett <br /> p ,. °y 201 W.Washington Ave., P.O.Box 7162 Sanitary Permit Number(m he idled in by Co) <br /> F Madison,WI 53707-7162 p <br /> �q'0sxwxx'� <br /> Sanitary Permit Application State Tmnmenar Narter <br /> In acroniano with SDS 38321(2),Wis-Adm.Code,submission of Ihis form to the appmprime govemernind unit Project Address 6f diBcrent that mailing address) <br /> is required prior to obmining a sensory prom[. Note:Application forms for stmeuwned R WTS are submined to <br /> the Deparlmcnt of Safny and Profsional Servies. Personal information you Inovide may he it for secondary Same �//y� 1 <br /> . p_I-v <br /> in accordance wiN the Priv Law,s. 15 04(1)m,Son, rlb7(( Co(- I`(_ JJ <br /> I. <br /> Application Information-Please Print All Information <br /> Property Owner's Name Parcel4 <br /> Ethan Hayes / � 07-0114-2-38-15-214 03-000-011000 <br /> Pmpeny Owner's Mailing Address ( Property I.ucatioa <br /> 4673 County Rd.B Govt_wt <br /> City,State zipCode Phone Number SW v..SE r, seerinn 21 <br /> Frederic WI 54837i rncone) <br /> 138N; R15 E <br /> IL Type of Building(cheek all that apply) Into <br /> Q I or 2 Family Dwelling-Numberoftledrooms 3 Subdivision Name <br /> Bloch# <br /> ❑WbliesCorran isl-Dacrlbp Use 11 City of <br /> 11 State Owned-DesaiMUse CSM Number ❑Village of <br /> 9 Town or Lafollette <br /> III.Type of Permit-. (Check only one box oo line A. Complete line B if applicable) } - <br /> A' ❑ New System 13 Replacement System ❑Treannent/lIdding Tank Replacement Only ❑Olhn Modification to Existing System(explain) <br /> B. IPrnnit Renewal ❑ Yermil Revision ❑Chrngenfphinder Owner❑Pzrd't Transform New List Previous Permit Number and Dare Issued <br /> Before Expiration <br /> IV.Type of POWTSS stem/Com onent/Device: Check all that apply) <br /> ®Non-PnxsmirriIn-Ground ❑ Pressunudhi4inand ❑ AHimdc ❑ Mears1>24in.ofsoubdesail ❑ Mound<24in.ofsuitablewil <br /> ❑ Uolding Tank ❑Olher Disyersal Componem(expern) ❑Pmosta neat Device(explain) <br /> V.Dis rell/Treal em Area Information: <br /> Design Finan(gpd) Drop Sol Application Ratc(gioll Dispersal Arra Required(sf) Dispersal Arca Proposed(sf) System Elevmion <br /> 450 .7 643 680 Elsa 94.90' <br /> VI.Tank Info Cepmity in Tolald of Mwuraeon. <br /> Gallons Gallons Unit t? <br /> New Tia" F-s int Tanks e y a i3 <br /> a`U u U a <br /> Seprmaremde,lio, 10001000 1 Wieser Concrete X <br /> 600 600 Combination <br /> VII.Responsibility Statement- Can,undersigned,assume responsibility or asidd adon of the POWTS shown on the arched plana <br /> Plumber's Name(Inas) Plumbe' ign MP/MPRS Numhr Business Phone Number <br /> Robert Carlson 135655 715-653-2500 <br /> Plumbn's Address(Snen,City,Score,zip Code) <br /> 3572 115''St. Frederic WI 54837 <br /> Ill.Count /De irtment Use Col <br /> Approved ❑ Disnppmved Permit Fee Da41 sued Issui ent Signa <br /> ❑Owner <br /> IX.Conditions of Approval/Reasons for Disapproval D ���❑1 rh. <br /> AUG 28 2013 D <br /> Aaaeh m romolae phos for the aYstw aM eunmT ro roe C"vnn oey on wPrr.oum rLo a in x u ia.4 <br /> tfFiNETT COUNTY <br /> ZONING <br />