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Sanitary Permit Application Safety&Buildings Division <br /> In accord with Comm 83.21,Wis.Adm. Code 201 W.Washington Ave. <br /> Wisconsin <br /> See reverse side for instructions for completing this application PO Box 7302 <br /> Personal information you provide may be used for secondary purposes Madison,WI 53707-7302 <br /> Department of Commerce [Privacy Law,s. 15.04(1)(m)] (Submit completed form to county if not <br /> state owned.) <br /> Attach complete plans(to the county copy only)for the system,on pap not less than 8-1/2 x 1 I inches in size. <br /> County State S 'tary Perini[Number ❑CAeck if virevio application State Plan I.D.Number <br /> Burnett 3 <br /> I.Application Information-Please Print all Infor ation Location: <br /> Property Owner Name Property Location <br /> Stebe & Kathy Metcalf GL 3 1/4 1/4,s 12 T39 ,N,R1vo/r wr <br /> Property Owner's Mailing Address Lot Number Block Number <br /> 331 SooLIne Road 4 na <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Hudson WI 54016 715-425-7729 Lipsie Pines Sub II <br /> II.Type of Building: (check one) ❑city <br /> ❑ 1 or 2 Family Dwelling-No.of Bedrooms: 3 ❑Village <br /> ❑Public/Commercial(describe use):_ 10 Town of Rusk <br /> ❑ State-Owned <br /> Nearest Road Palmer Lane <br /> Pargig N be <br /> III.Type of Permit: (Check only one box on line A. Check box on line B if applicable) <br /> A) 1. IRNew 2. ❑Replacement 3. ❑Replacement of 4. 5. 6. ❑Addition to <br /> System System Tank Only Existing System <br /> B) Permit Number Date Issued <br /> ❑A Sanitary Permit was previously issued <br /> IV.Type of POWT System: (Check all that apply) <br /> P Non-pressurized In-ground ❑Mound ❑Sand Filter ❑Constructed Wetland <br /> ❑Pressurized In-ground ❑Holding Tank ❑Single Pass ❑Drip Line <br /> ❑At-grade ❑Aerobic Treatment Unit ❑Recirculating ❑Other: <br /> V.Dispersal/Treatment Area Information: <br /> 1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application 5.Percolation Rate 6.System Elevation 7.Final Grade <br /> Required Proposed Rate(Gals./day/sq.ft.) (Min./inch) Elevation <br /> 450 643 643 .7 -- 92.20 97.00 <br /> VII.Tank Capacity in Total #of Manufacturer Prefab Site Steel Fiber- Plastic <br /> Information Gallons Gallons Tanks Con- Con- glass <br /> New Existing crete structed <br /> Tanks I Tanks <br /> 1000 -- 1000 1 Wieser Concrete 0 ❑ ❑ ❑ ❑ <br /> boo — �'Xl f " coma JgL ❑ ❑ ❑ ❑ <br /> VIII.Responsibility Statement <br /> I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(print) Plu is Signa re(n ps): MP/MPRS No. Business Phone Number <br /> Donald Daniels MP 330/221593 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip ode) <br /> PO Box 316 Siren WI 54872 <br /> IX.County/Department Use Only <br /> ❑Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing ent n o stamps) <br /> Approved ❑Owner Given Initial Adverse Surcharge Fee) ,�mm <br /> PP Determination �wkd r UV ,j A6G,Q� <br /> X.Conditions of Approval/Reasons for Disapproval: <br /> SBD-6398(R 07/00) <br />