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GornnierCe.wi.golf Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> sco n s i n Madison,W 153707-7162 Sanitary Permit <br /> ruDlepwbuient Number(to be filled in by Co.)of cunanarm 54D 4)3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Conus.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental Owt-�� `C V 1 Bln.) <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(ifdifferem[than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15. t m,stats. 12043 Little Trade Lake Rd. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name I Parcel# o3L�_( 3 I-L)4-00 O <br /> Blossom Management and Development Co.(Kevin and Laura Fossum) <br /> 07-034-2-37-18-21-5 05-003-032000 <br /> Property Owner's Mailing Address Property Location <br /> 12025 Little Trade Lake Rd. <br /> Govt.Leta Section 21 <br /> City,State Zip Code Phone Number (circle one) <br /> Grantsburg WI 54840 715-488-3990 T 37 N; R18 E m W <br /> D.Type of Building(check all that apply) Lot# 0 <br /> ❑ I or 2 Family Dwelling-Number of Bedrooms 3 1 and Outlot 1 Subdivision Name <br /> Block# <br /> ❑Public/Commacial-Describe Use <br /> ❑City of <br /> ❑State(Tuned-Describe Use CSM Number ❑ Village of <br /> vol.4 Pg.114 ❑Town of Trade Lake <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System Replacement System ❑Treatment/Bolding Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> tV.Type of POWTS S stem/Com onent/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.DispersalfIrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Na Na i Na) Na <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o'er v <br /> New Tanks Existing Tanks w o ' <br /> 4.U rn rn P. O P, <br /> Septic or Holding Tank 2500 2500 1 Wieser Concrete X <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) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Robert Carlson <br /> MPRS#135655 715-053-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572115th St. Frederic WI 54837 <br /> VIIJ.County/Department Use Only <br /> jtXApproved 11 Disapproved Permit Fee Date Issued Issuing [ store <br /> S mi <br /> LlAis 1 <br /> owner Given Reason for Denial 37. w �� kt) <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> FIRM 1kap i�-r Baric-6 ccz t,/ Uev 45. /9,, 2oo8, tndtcak% sk as <br /> Ct7E of 14od t)IJwn. <br /> Atnch incomplete plan for the system and submit to the County only on paper not lem Hoe a in x 11 inchm ie size <br /> SBD-6398(R.02/09)Valid thru 02111 <br />