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ur County <br /> Industry Services Division BURNETT <br /> 1400 E Washington Ave <br /> a s� <br /> P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 38321(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 I m),Stats. <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> MICHAEL R&KATHLEEN S OLSEN 07-032-2-41-15-04-5 15-063-014000 <br /> Property Owner's Mailing Address Property Location <br /> 5078 BURLS TRL <br /> Govt.Lot <br /> City,State Zip Code Phone Number /., 'A, Section 4 <br /> DANBURY,WI 54830 (circle one) <br /> T41N; R15WEorW <br /> 17.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling—Number of Bedrooms 4 Subdivision Name <br /> BURL'S ACRES LOT 4 <br /> ❑Public/Commercial—Describe Use Block# <br /> ❑ City of <br /> ❑State Owned—Describe Use <br /> CSMNumber ❑ Village of <br /> ® Town of 5(,t,i<j <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ® Replacement System ❑ TreatmentlHolding 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. Type of POWTS S stem/Com onent/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 /> 450 Rate(gpdsf) 642.86 642.86 96.0' <br /> .7 <br /> VI.Tank Info Capacity in <br /> Gallons Total #ofManufacturer <br /> Gallons Units <br /> New yanks Existing Tanks a. U =n vi W.C7 a <br /> Septic or Holding Tank 1000 1000 1 WIESER CONCRETE ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber I ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume re onsibility for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si 41 MP/MPRS Number Business Phone Number <br /> CORY JACKSON 7° 824339 715-566-2786 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 BLACK BROOK RD. WEBSTER,WI 54893 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved PermitFeeDate,Isssued Issuing Agent Signature <br /> El Owner Given Reason for Denial $ 8ee��� S <br /> IX.Conditions of Approval/Reasons for Disapproval ^ �n n <br /> D '(VU" U <br /> MAY 12 2015 <br /> Attach to complete plans for the system and submit to the County only on paper not Iris 11 inches is size <br /> BURNER COUNTY <br /> SBD-6398(R03/14) ZONING <br />