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commerce.wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> i sco n s i n Madison,WI 53707-7162 Sanitary'Permit Number(to be filled in by Co.) <br /> .epartimeM of Cotlmbrrs 5`Co 3 7l0 <br /> Sanitary Permit Application State act nn Nu�^be <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental n•E �F,(lt2tr) <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 <br /> purposes in accordance with the Privacy Law,s. 15. 1 m,Stats. 28990 Spring Green Way <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Prow" 07-02$-2.40•1y-07-5 /5-704- <br /> Tom Sadlicki , L <br /> 028-9375-02 900 <br /> Property Owner's Mailing Address Property Location <br /> 10092 West Campfire Circle <br /> Govt Lot 3 <br /> City,State Zip Code Phone Number _'/., 'h, Section 7 <br /> Hayward WI 54843 715-462-3925 (circle one) <br /> 11.Type of Building(check all that apply) Lot# T 40 N; R 14 E or W <br /> 1 or 2 Family Dwelling-Number of Bedrooms_ 2 19 Subdivision Name <br /> Block# Spring Green Add.To Voyager Village <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> ❑ Town of Scott <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A, 9 New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal El Permit Revision El Change of Plumber ❑Perini[Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com oneut/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.Dispersalffreatment Area Information: Quick 4 Standard—W Chambers Eisa Rating of 20.00 sq.ft. <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Arca Proposed(sf) System Elevation <br /> 300 .5 600 600 95.50 <br /> VL Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units <br /> New Tanks Existing Tants c v <br /> o.U u. 0 P. <br /> sepia or Holding Tank 750 750 1 Wieser Concrete X <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the unde I ne4rwsume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) A 's Si atu / MP/MPRS Number Business Phone Number <br /> Dayton Daniels <br /> MPRS#007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Boa 326 Siren WI 54872 <br /> VIII.Cour /De artment Use Only Approved El Disapproved Permit <br /> �Fee <br /> Date Issued 7"��,, Issuing t � ature <br /> El Owner Given Reason for Denial f 32 J / 240 <br /> IX,Conditions of Approval/Reasons for Disapproval <br /> Arl ECEiEnn <br /> Athth to complete plow for the system and sabmit to are County only on paper not less thma UU <br /> i 1466 i <br /> BURNETT COUNTY <br /> SBD-6398(R.02/09)Valid thru 02/11 ZONING <br />