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COfI1IT1@fC@.WI.gOV Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> scoM ns i n Madison,WI 53707-7162 Sanitary Number(to be filled in by Co.) <br /> Of c maarce /QU rTf <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),W is.Adm.Code,submission of this forth to the appropriate governmental —,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 Spirit Lake Access Rd. <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Boyd Dufour / 034-9025-01400 <br /> Property Owner's Mailing Address (� Property Location <br /> 21845 Spirit lake Access Rd. <br /> Govt Lo[ 2 <br /> City,State Zip Code Phone Number Section 12 <br /> Frederic Wi 54837 715-327-8809 T37N; R18Ec (circle one) <br /> � <br /> H.Type of Building(cheek all that appy) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms 2 4+5 Subdivision Name <br /> Block# Lots 4+5 of Loafers Bend Sub. <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number 11 Village of <br /> ❑ Town of Trade lake <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System 0 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 7457A 8/21/79 <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) Pump Tank Reolacement ❑Pretreatment Device(explain) <br /> V.Dis ersaVTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 .7 428 432 existing Approx. 100.00' <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units r?d P <br /> New Tanks Existing Tanks <br /> U .n <br /> septic or Holding Tank 750 750 1 1 1 Wieser Concrete x <br /> Dosing Cbamber 750 750 1 1 1 Wieser Concrete x <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibilityor installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) PlumFMP/MPRS Number Business Phone Number <br /> Robert Carlson �1 135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572 115"Street Frederic WI 54837 <br /> VIIL Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit F//ee D/a(tAe Issuedy" r Issuing Age store <br /> Ll Owner Given Reason for Denial $ — <br /> IX.Conditions of Approval/Reasons for Disapproval D.MP -fWI< ?Z4(,.AC6jt4 J'f' O-AJ <br /> Match to complete plans for the system and submit to the County only on W per not less than s In x 11 inchesin size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />