Laserfiche WebLink
Arracn to complete plans for the system ana suomit tome County only on paper not less than 5 1/2 x 11 inches in size r LU I r <br />T r-❑UNTY <br />SBD -6398 (R03/14) ��, <br />County <br />rr°° ti <br />Industry Services Division <br />Burnett <br /># *1, <br />�;' <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />Madison, WI 53707-7162 <br />604698 <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 38321(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 <br />Project Address (if different than mailing address) <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />Town Hall Rd <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />NICHOLAS J & RACHEL STADLER <br />07-008-2-38-14-33-2 02-000-011000 <br />Property Owner's Mailing Address <br />Property Location <br />N2961 SUNSET DR <br />Govt. Lot <br />nw'/4, nw V4, Section 33 <br />City, State <br />Zip Code <br />Phone Number <br />Shell Lake, WI <br />54871 <br />(circle one) <br />T38N14; RWEorW <br />II. Type of Building (check all that apply) <br />Lot # <br />® 1 or 2 Family Dwelling — Number of Bedrooms <br />Subdivision Name <br />❑ Public/Commercial — Describe Use <br />Block # <br />❑ City of <br />❑ State Owned — Describe Use <br />❑Village of <br />CSM Number <br />® Town of Dewey <br />III. <br />T e of Permit: Check only one box on line A. Complete line B if a licable) <br />A. <br />® New System <br />❑ Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />Owner <br />IV. <br />Type of POWTS System/Component/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. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />450 <br />Rate(gpdsf) <br />900 <br />918 <br />90-86.5 <br />.5 <br />VI. Tank Info <br />Capacity in <br />Gallons <br />Total # of <br />Manufacturer <br />0v <br />° <br />New Tanks Existing Tanks <br />Gallons Units <br />o <br />w U <br />;; <br />vi v <br />v C7 <br />ki. <br />Septic or Holding Tank <br />x <br />1000 I <br />Wieser ® <br />❑ ❑ <br />❑ <br />1 ❑ <br />Dosing Chamber 1❑ <br />❑ ❑ <br />❑ <br />El <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />P re <br />MP/MPRS NumberBusiness <br />7715-468-2434 <br />Phone Number <br />Luke Schmitz <br />884121 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO Box 160 Shell Lake WI 54871 <br />VIII. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />�7 o <br />Date Issued <br />Issuing Agent Signature <br />V", f_,CQ�� <br />Owner Given Reason for Denial <br />$ 3/ S' D <br />'ol / - 7 <br />IX. Conditions of Approval/Reasons for Disapproval <br />( ' <br />.etr <br />YY l� <br />Arracn to complete plans for the system ana suomit tome County only on paper not less than 5 1/2 x 11 inches in size r LU I r <br />T r-❑UNTY <br />SBD -6398 (R03/14) ��, <br />