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rsl Industry Services Division Burnett <br /> ' p$ 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P$ P.O. Box 7162 <br /> Madison, <br /> +a iWI 53707-7162 <br /> ��aayrrav,�� <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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. 4650 lake 26 Road <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Thomas and Karen Schaaf 07-032-2-41-15-22-5 05-002-018000 <br /> Property Owner's Mailing Address Property Location <br /> 1151 East La Salle Ave. <br /> Govt.Lot 2 <br /> City,State Zip Code Phone Number /4, %4, Section 22 <br /> Barron,WI 54812 (circle one) <br /> T41 R15EorW <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms Na Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> [I City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> Na ® Town of Swiss <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ® New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ® Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T e 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: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 Ratc(gpdsf) 429 EISA of 440 91.20'+90.50' <br /> .7 <br /> VI.Tank Info Capacity in <br /> c <br /> Gallons Total #of Manufacturer m U Z U <br /> Gallons Units u o 2 -2 <br /> 9 A <br /> New Tanks Existing Tanks a U �n 3 i1 <br /> Septic or Holding Tank 800 800 1 Huffcutt Concrete ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber' � atle� MP/MPRS Number Business Phone Number <br /> Luke Schmitz i�� l ' 884121 715-468-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 160 Shell Lake WI 54871 <br /> V II.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Oo Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial S 3 7 5' <br /> IX.Conditions of Approval/Ressons for Disapproval Lo jtS 'o Qe Z-O w r Pe/ 6&v %Ac A,I o{Za vd 6/5 t Perm"� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/1 x 1I inches in size <br />