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COrt1Zn <br /> I.gOV Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> 'C/mC 1,v Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> mnterce <br /> Sanitary Permit Application state Tram 1!o Number <br /> In accordance with s.Comm.S .21(2),W is.Adm.Code,submission of this form to the appropriate governmental Transit <br /> unit is required prior to obtai ing a sanitary permit. Note: Application forms for stateowned POWTS are Project Address(if different than mailing address) I n) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary V <br /> purposes in accordance with the Privacy Law,s. 15.04(I m Slats. 4309 County Rd.B <br /> I. Application Informatio -Please Print All Information <br /> Property Owner's Name IParcel# <br /> Maynard and Ronda Mllangelsen <br /> . /I 07-014-2-38-15-.iX- 2-0oo 011000 <br /> Property Owner's Mailing Ad ess Property Location <br /> 22516 No Outlet Rd. <br /> Govt.lot <br /> City,State Zip Cade Phone Number NW '/.,SE%. Section 22 <br /> Shell Lake WI 54871 715468-2219 (circle one) <br /> T 38N; R 15 E or W <br /> 11.Type of Building(cheeI all that apply) Lot# <br /> 1 or 2 Family Dwelling—Npmber of Bedrooms 2 Subdivision Name <br /> Block# <br /> 0 Public/Commercial—Describe Use <br /> ❑City of <br /> 0 State Owned—Describe Us, CSM Number 0 village of <br /> M Town of LBFollette <br /> III.Type of Permit: (Ch k only one box on line A. Complete line B if applicable) / — as O <br /> A. 0 New System Replacement System 0 Treatmenb'Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of Plumber 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S st m/Com onent/Device: Check all that apply) <br /> Non-Pressurized In-Group 0 Pressurized In-Ground 0 At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> 0 Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Infiltrator Quick 4 Standard W-Chambers Eisa Rating=20s .ft. <br /> Design Flow(gpd) Desi Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 300 .6 500 520(Eisa) 94.90' <br /> VI.Tank Info Capacity in Total 4 of Manufacturer <br /> Gallons I Gallons Unitsa V New anks Existing Tanks v o v a is <br /> a U ur <br /> Septic or Holding Tank 756 1 Wieser Concrete X <br /> tbsing Chamber <br /> VII.Responsibility State ent- I,the undersigned,assume responsibility Nr installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's5ai mato MP/MPRS Number Business Phone Number <br /> Robert Carlson <br /> G� MPRS#135655 71553-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572 11501 St. Frederic WI 54837 <br /> VIII oun /De artmen Use Only <br /> Approved 0 Disappri ved Permit Fee Date Issued Issuing igna[ure <br /> 0 Owner Given Reason for Denial <br /> 11-a1-� I <br /> OL Conditions of Appro ialfReasons for Disapproval Dtom- O0 <br /> NOV 81 2011 }7 <br /> iAttach 0 wmphKe plana for the system and submit to the Comity only on paper not kms than a in x 11 iacheStMN� <br /> a+vrl ZONING <br /> SBD-6398(R.02/09)Valid film 02/11 <br />