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eommememl.gov Safety and Buildings Division County <br /> ifiblib 201 W. Washington Ave.,P.O.Box 7162 Burnett <br /> 'Wisconsin Madison,WI 53707 7162 Sanitary Permit Number(to be filled in by Co.) <br /> IdofCoaal� 55 110 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental (.aim PGUr CcJ <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for stateowned 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 <br /> ses in accordance with the Privacy Law,s. 15.04 1 m,Slats. FN# 12230 Pickerel Point 4� <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> John Romanowski -W3 <br /> , `1`1 y 07-0342-37-18-21-5 05-004-0180011 <br /> Property Owner's Mailing Address Property Location <br /> 8800 Lexington Ave. <br /> %.,%., <br /> City,State Zip Code Phone Number Govt Lot 4 Section 2(circle one) <br /> Lexington MN 55014 T 37 N; R 18 E or W <br /> 11.Type of Building(check all that apply) Lot# <br /> O I or 2 Family Dwelling—Number of Bedrooms 4A of D-Map D-167 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use ❑City of <br /> El State Owned—Describe Use CSM Number ❑ Village of <br /> i Town of Trade Lake <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) b7— <br /> A. ❑New System :i Replacement System Y p ys 0 TreatmenUHolding 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 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 /> I 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(st) Dispersal Area Proposed(sf) System Elevation <br /> 450 Na Na Na) Na <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units v c u <br /> New Tanks Existing Tanks <br /> 0 <br /> WU y J? H V. C7 d <br /> septic or Holding Tank 2000 2000 1 Wieser Concrete WLP X <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsi iW for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu Si M MP/MPRS Number Business Phone Number <br /> Robert Carlson <br /> MPRS#135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Cade) <br /> 3572 115th St. Frederic WI 54837 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing a ignature <br /> ❑ Owner Given Reason for Denial 375, ,v <br /> IX.Conditions of Approve I D �� ��� <br /> i;& Ap/kual e t eY d{ �krf i <br /> JUN 2 8 2011 <br /> Attack to complete plans for the system and submit to the County only on paper mot leas than 8 trz 1' hes im sire <br /> BURNETT COUNTY <br /> ZONING <br /> SBD-6398(R.02/09)Valid thrid 02/11 <br />