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fry County <br /> t 1r Industry Services Division Burnett <br /> r . <br /> �i` � 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> xJ WI P.O. Box 7162 <br /> Madison, 5370707-7162 <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 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 1341 Racine Dr. <br /> Durtioses in accordance with the Privacy Law,s. I5.04 1 m Slats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel 07_029—Z— —AV-13 <br /> Mark Just S /S= y3Z— oLlbow <br /> Property Owner's Mailing Address Property Location <br /> W6468 Ojibwa Rd. Govt.Lot <br /> City,State Zip Code Phone Number y., Y.., Section 13 <br /> Spooner W1 54801 (circle one) <br /> 11.Type of Building(check all that apply) Lot# T 40 N; R 14 E or W <br /> Q 1 or 2 Family Dwelling—Number of Bedrooms 2 31 & 32 Subdivision Name� / <br /> 14 <br /> Block# G01A� �G/tYNZiG e��/t <br /> ❑Public/Commercial—Describe Use 3 ❑City of <br /> ❑State Owned—Describe Use 7Number ❑ Village of <br /> Q Town of SCOtt <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A ❑New System Q Replacement System ❑Treatment/Holding 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 System/Component/Device: Check all that apply) <br /> Q 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.Dis ersaVrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 .7 429 450 97.0 <br /> N'1.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units d o'er o <br /> New Tanks Existing Tanks <br /> � U mC7 a <br /> Septic or Holding Tank 750 750 1 Wieser X <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibi ity 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 /> Rick Brown 1231251 419-0739 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 637 Spooner WI 54801 <br /> Vill.Coun /De artment Use Only <br /> Approved ❑Disapproved 'Perm Date Issued Issuing Agent Signatur <br /> 0 L/ <br /> ❑Owner Given Reason for Denial 1 <br /> S `3?7S / 7"01 / �7 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x I inches in size <br /> SBD-6398(R0313) <br />