Laserfiche WebLink
�og""n'eyT County <br /> Industry Services Division BURNETT <br /> ` P.O. Box 7162 <br /> 1400 E Washington Ave <br /> s Sanitary Permit Number(to be filled in by Co.) <br /> F <br /> ry� Madison,WI 53707-7162 s9�Sa 1 <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 Ole <br /> a 3 <br /> is required prior to obtaining a sanitary permit. Note:Application fors for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal infornuuion 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 /> JEFFREY P&ROBIN J SVENTEK 07-034-2-37-18-22-2 03-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> 11717 PINE LAKE RD <br /> Govt.Lot _ <br /> City,State Zip Code Phone Number SE'/4,NW'h, Section22 <br /> FREDRIC,WI 54837 715-327-8989 (circle one) <br /> T37N; R18W <br /> II.Type of Building(check all that apply) / Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms A Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑State Owned-Describe Use ❑ City of <br /> rScss <br /> M Number [I Village of <br /> M V 10 P 230 (IN SE NW) ® Town of TRADE LAKE <br /> III.Tpe of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ® Replacement System ❑ Treatmem(Holdin Re g Tank Replacement Only El 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 7-1r ` 6 <br /> IV.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 su' ble soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis ersaLlTrestment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 750 Rate(gpdst) 750 750 99.25' <br /> 1.0 <br /> VI.Tank Info Capacity in <br /> Gallons o <br /> Total #of Gallons Units Manufacturer g b U y <br /> d A <br /> New Tanks Existing Tanks U <br /> Septic or Holding Tank 1000/600 1600 1 WIESER CONCRETE INC. ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber 1000 1000 1 WIESER CONCRETE INC. ® ❑ ❑ ❑ ❑ <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 /> NELS KOERPER 225229 715-866-8608 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 7845 COUNTY RD.D WEBSTER,WI 54893 <br /> II.Coun /Department Use Only <br /> Approved ❑ Disapproved Permit Fee 4 Date/Issued 7 Issuing Agent Signature <br /> El Owner Given Reason for Denial $ 37 D !� '�'� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> MAY 3 0 2017 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x It in' itra ETT COUNTY <br /> ZONING <br /> SBD-6398(1103/14) <br />