Laserfiche WebLink
ifilimb Comrrierce.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> sco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> 'Wisconsin <br /> epartment of Commerce S2_ 1 o 2, <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 .�. <br /> unit is required prior to obtaining a sanitary pennit. Note: Application forms for stateowned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal infonnation you provide may be used for secondary Same <br /> es in accordance with the Privacy Law,s. 15.04(l m,Stats. <br /> 1. Application-Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Paul Reis &]i <br /> 006-2433-02-500 <br /> Property Owner's Mailing Address Property Location <br /> 22541 Old 35 Govt Lot <br /> City,State Zip Code one Number NEI/4-SEI/4 (circle one)Section 33 <br /> Siren WI 54872 715-327-8356 T 38N; R 17 E or© <br /> IL Type of Building(cheek all that apply) Lot# <br /> I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 11 Town of Daniels <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ®Replacement System ❑ Treaunent/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 <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> *Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade 0 Mounnd�>24 in,of suitable soil El Mound<24 in.of suitable soil <br /> El Holding Tank IP Other Dispersal Component(explain)_ �2drM� C-?A4e ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: Infiltrator Quick 4 Standard-W Eisa=20 sq.ft. <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requned(st) Dispersal Area Proposed(sf) System Elevation <br /> 450 .7 643 680sq.R Based on Eise of Cel1#1 =91.00' <br /> z0 sq.R.x 34 units Cel1#2=91.00' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units d $ ^ <br /> New Tacks Existing Tanks -9i= v <br /> a U in rn �C7 i% <br /> Septic-Holdiag Tack 1000 <br /> 1000 1 Wieser Concrete x <br /> Dosing Chvabw <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plurnigms Signamr MP/MPRS Number Business Phone Number <br /> Robert Carlson 135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572115"Street Frederic WI 54837 <br /> VIII.Cozen /Department Use Only <br /> ❑ Approved ❑ Disapproved Permit Fee Date Issued Issu It Sign <br /> 11Owner Given Reason for Denial $ 300 Iq8 y 0 Uqc <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 1l inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />