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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> rsconsin Madison,WI 53707 7162 Sanitary Permit Number(to be filled in by Co.) <br /> "�°' 551128 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental ) 11 8707 <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 /> purposes in accordance with the Privacy Law,s.15.04 l m,Slats. Same <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Willis Mclain 07:034-1'37-13-/5-3 03-OCO-0/41-oo0 Ill, <br /> 0 07-034-2-37-18-22-2 02-000-013000 <br /> Property Owner's Mailing Address Property Location <br /> 21194 School House Rd. Parti a(-A-:W*4-5V# &cfa /5 ; <br /> PAA aFthr-NINyp NW %, Section 22 <br /> City,State Zip Code Phone Number (circle one) <br /> Frederic,WI 54837 715-327-5540 T 37 N; R 18 E or W <br /> Il.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms_ 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 11 Town of Trade Lake <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) 03q - ' <br /> A' ❑ New System ■Replacement System ❑TreatmentlHolding 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 /> IV.Type of POWTS S stem/Com onent/Device: Check all that a 1 <br /> ❑Non-Pressurized In-Ground i 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.Dis ersaUTreatment Area Information: EZ Flow 1203H Eisa Rating of 50 sq.ft-30 sq. for this application <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(s0 Dispersal Area Proposed Is System Elevation <br /> 300 1.0 300 300 93.58' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o d 2 <br /> New Tanks Existing Tanks <br /> U <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete X <br /> Dosing Chamber 600 600 Combination X <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility,for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) A 's Si / MP/MPRS Number Business Phone Number <br /> Dayton Daniels MPRS#007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 326 Siren WI 54872 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date IsYsue'd/ Issuing t gnature <br /> 11Owner Given Reason for Denial SO75.�i� ,?7�jVI y 2D 1' 4 <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Tia 8 : IndlulLuaJ Srfe deSKjA For+a 'In 5rdu,td Nth ' 6ytC .kit AbsMPE+pr G 1. <br /> Atlacb to complete plansfor the system and submitto the County only on paper not less than Sin x It inches is size <br /> SBD-6398(R.02/09)Valid thou 02/11 <br />