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�oas•ameq Conan, <br /> y1.1 °^ Industry Services Division Burnett <br /> 0 : 1400 E Washington Ave <br /> P P.O.Box 7162 <br /> Sanitary Permit Number(to be filled in by Co.) <br /> $ <br /> Madison,Will 53707-7162 5'773-39 <br /> Sanitary Permit Application Smu Iron tion Number <br /> In accordance with SPS 383.21(21.W is.Adm.Cods submission of Nis Rmn to Ne vpmpnac govemmental unit <br /> required prior m obtaining a sanitary permit Note:Application to.,for state-owned PDWTS arc submived to <br /> the D panment of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if dlBerem than mailing address) <br /> to accordve wish <br /> xthe Pri law,s. 15,04(1 m),Stats. 9707 N.Mudhen lake Drive <br /> I. Application Information-Please Print All Information <br /> property 's Name Parcel <br /> Ryan and Kate flasher 07-M-2-3%-17-16-5 05-006019000 w 02000 <br /> Property Owner's Mailing Address Property Locution <br /> 810 Juniper Street <br /> Govt Let 6 <br /> City,State ZipCdc Phone Number vto A. VIJ V... Section 16 <br /> Somerset,Wl 54025 651-091-7164le one <br /> T3%N R17B <br /> II.Type of Building(check all that apply) hot p <br /> ® Ior2FamilyD -IIing-Numberuf Bcdmvma Na Subdivision Name <br /> ❑PublirMommereial-Describe Use Block a <br /> [I City <br /> ❑State Obvned-Ixsenloe Dae <br /> CSM Number ❑ Villagege of <br /> ® Town of Daniels <br /> IIL'!ype.!Permit: Check only one box on line A. Complete line B if applicable) <br /> A_ ® New System ❑ Replueemen System ❑TteabneMHolding Talk Replacement Only ❑ g6er Mdiliratimp.Eisdne Sntcm(espload <br /> B. E) permit Renewal ❑ Permit Revision ❑Change of ❑Pemtit Transfer to New List Previous permit Number and Date Issued <br /> Bet l:xpirmicn Plumbs (hma <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ❑ Non-Pressur ad lnLaard ❑ Prasurixd lmGmwd ❑ AtLmde ❑ Moand>24 in.ofsuitable sod ❑ Mound<24 in.ofsuimble soil <br /> [AIlolding Tank ❑Other Dispersal C'omlament(esplain) ❑Pretrtatmrnt Levi.o,splain) <br /> V.Dis ersaVl'reatment Area Information: <br /> Design Be,(gp) Cesip Soil Application Dopersal Area Required Is Dispersal Area proposed(11) System Elevation <br /> Rmggpdsf) <br /> VI.Tank Info Capacity in <br /> GaJ oro 'total 4 of <br /> Mamfactumr -_ <br /> New Tanks Esiaivg Tanks GaiIOnS UnilS y <br /> Septic or l folding Tests 1 O 2000 1 Wieser Concrete ® ❑ ❑ El El <br /> Dosing Clamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- 1,the undetxigned,assume responsibility for installation orthe POWfS shown on the attached plans. <br /> Plumber's Name(Not) Y,lumb/e�r')s�Signaure MP/MPRS Number Business Phone Number <br /> Willie Kaufmann 715-766-3493 <br /> Plumber's Address(Sweet,City.State,Zip Code) <br /> WI949 Co.liwyC Springbmok. WI. 54875 <br /> VIII.County/Department tJse Onl <br /> (PApproved ❑ Disapproved I Permit Fee Dau Issud Issuing Agent Sigrid. _ <br /> ❑ Dwner Given Reason far Damd s 3?Soo ;a-6 yy <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Rn, <br /> ^���� <br /> /hi757Z� ®L(.frvlgQL 70 It— /RESt�✓✓'(� Qaut7f�/ti6PEZ7Tw✓. �IIU/" <br /> OCT 3 2014 <br /> emmru romPkn Pum ronnryvrm.aa ranmato me cw . aril.oa P,per onto..maaem.n+� <br /> BURNETipOGNTy <br /> SBD-6398(R03/14) ZONING <br />