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comrnerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> i sco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> t.sparhm 51 103 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Cade,submission of this form to the appropriate governments] <br /> —r> <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> u ores in accordance with the Privacy Law,s. 15.04(Ixm,Stats. <br /> 1. Application Information-Please Print All Information 2260Z O/d '55 <br /> Property Owner's Name Parcel# <br /> Bill Siebenthal n_ 006-2434-02 000 <br /> Property Owner's Mailing Address (� Property Location <br /> 22602 Old Highway 35 Govt.Lot <br /> SWIWNWl/4 Section 34 <br /> City,State Zip Code Phone Number /� (circle one) <br /> Siren WI 54872 715-6534265 T 38N; R 17 E o1 w <br /> H.Type of Building(ckeck all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms 3 Lots Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM NumberElVillage of <br /> 7 9 Town of Daniels <br /> Ill.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A' ❑ New System Y Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. El Permit Renewal El Permit Revision [I Change of Plumber ❑Penni[Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/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.Dispersal/Treatment Area Information: Infiltrator Quick 4 Standard-W Chambers Elsa of 20 s ,ft. <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sI) System Elevation <br /> 450 .7 643 680 sq.ft.Based on Dan of Cell#1 =91.80' <br /> 20 sq.R.x 34 units Cell#2=91.80' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units 'g o$ v <br /> New Tanks Existing Tanks ''� o U <br /> � ! � a . <br /> SU <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete X <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned, respon ' ilitymstollatlon of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum 's gnatur MP/MPRS Number Business Phone Number <br /> Robert Carlson 135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572 115rh Street Frederic WI 54837 <br /> VIII.County/Department Use Only <br /> Or'Approved ❑ Disapproved Permit Fee Date Issued Issuing attire <br /> me <br /> Given Reason for Denial S & � M i y .� rr <br /> 1X.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plana for the system and submit to the County only on paper not has than 8 tR z Il inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />