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�`r�r�anugyr <br /> County <br /> a I Industry Services Division Burnett <br /> 1� ® 1400 E Washington Ave <br /> 3 $ <br /> P.O. Box Sani Permit Number(to be filled in by Co.) <br /> / n n� <br /> Madison,WI 53707707—7162 -�' 11 j �(J <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 statoowned 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 /> purposesin accordance with the Privacy Law,s.15.04(1)(m),Stals. Near FN# 24156 Swenson Rd. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Tom and Grace Haines 07-006-2-38-17-11-3 02-000-012000 <br /> Property Owner's Mailing Address Property Location <br /> P.O.Box 3 <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW'/,,SW'/4, Section I I <br /> Siren ,WI 55427 715-349-5650 le one) <br /> T38N R 17Eo W <br /> H.Type of Building(check all that apply) �} Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 6 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑State Owned-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> Na ® Town of Siren <br /> in.Type of Permit: Check only one box on line A. Complete line B if applicable) <br /> A. ®New System ❑Replacement System I] Trea ment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit'rransfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: Check all that 1 ) <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 opus (sl) System Elevation <br /> 300 Rate(gpdsf) Na Na Na <br /> Na <br /> VI.Tank Info Capacity in <br /> Gallons Total #ofo <br /> Gallons, Units Manufacturer „�� c ,U, <br /> New Tanks Existing Tanks 'V vi9 rn A <br /> Septic or Holding Tank 2000 2000 1 Wieser Concrete Products ® EJ ❑ ❑ ❑ <br /> Dosing Chamber 1200/800 Combo ❑ 0 ❑ ❑ ❑ <br /> VII.Responsibility Statement-1,the undersigneAnssupe responsi ''ty for installation of the POWTS shown on the atteebed plans <br /> Plumber's Name(Print) Signa��e MP/MPRS Number Business Phone Number <br /> Dayton Daniels h �( 007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 326 Siren WI 54872 <br /> VIII.Cour /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee <br /> , pDate Issuedr Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ t.3 /l7 r <br /> UL Conditions of Approval/Reasons for Disapproval <br /> D C�CENE <br /> Attach to complete plams for the system and submit to the County only on paper not less than 8112 z 11 int i SEP — h 2015 <br /> BURNETT COUNTY <br /> ZONING <br />