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Q+ r� <br /> ounty <br /> Industry Services Division BURNETT <br /> �! 1400 E Washington Ave <br /> Sanitary Permit <br /> /N_ her(to be filled in by Co.) <br /> F.O. Box 7162 <br /> = Madison,WI 53707-7162 sgOeX <br /> A4 61q -_ <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 state-owned 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 /> purposes in accordance with the Privacy Law,s. 15.0 1 m,Stats. <br /> L Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> LAWRENCE BESTLER 07-024-2-39-14-10-5 05-005-014000 T.AX#15777 <br /> legacy#024311005100 <br /> Property Owner's Mailing Address Property Location <br /> 26577 HII L ROAD P.O.BOX 631 <br /> Govt.Lot 5 EX 489/285 <br /> City,state Zip Code Phone Number '/4, 1/t, Section 10 <br /> SPOONER,WI 53153 651 278 3728 (circle one) <br /> T39N R14EorW <br /> IL Type of Building(check all that apply) Lot# <br /> ® I or 2 Family Dwelling-Number of Bedrooms ,3 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> El City of <br /> El State Owned-Describe Use <br /> SM Number ❑ Village of <br /> C <br /> r6.59 ACRES ® Town of RUSK <br /> III. a of Permit: Check only one box on tine A Complete line B if applicable) <br /> A ❑ New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.T of POWTS S stem/Com nent/Dcvice: (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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 643 650 >87.8'<99.8' <br /> .7 <br /> VL Tank Info Capacity in <br /> .! c <br /> Gallons Total #of o � `•' <br /> Gallons Units Manufacturer <br /> New Tanks Existing Tanks U m �v. to X 0 P. <br /> Septic or Holding Tank 320 1000 1320 existing 1000+new Skaw ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signa a MP/MPRS Number Business Phone Number <br /> Mel Ferguson dba &K SEPTIC & EX AVATiON MPRS 224879 <br /> Plumber's Address(S <br /> SP ONR, WI 54801 <br /> 7114,635-742 <br /> VIII. Coun /De artment Use Ont <br /> Approved ❑ Disapproved Permi?t Fee O Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial S 3 7S �0 '/ .lGa'if/� <br /> DL Conditions of Approval/Reasons for Disapproval E CEnnn <br /> "vr, L v <br /> OCT 14 2015 <br /> Attach to complete plans for the system and submit to the County only on paper not less than a 1/2 s 11 inc es in size <br /> BURNZETT COUNTY <br /> )D5 lo " <br />