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J <br />r <br />I . 11 ., .l n <br />arar <br />County <br />ate! <br />Industry Services Division <br />Burrett <br />r: a <br />1400 E Washington Ave <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />�a <br />qV '] <br />Sanitary Permit Application <br />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 />Project Address (if different than mailing address) <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. <br />27954 County rd FF <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />Jon & Luke Schmitz <br />07-036-2-40-17-26-5 05-001-012000 <br />Property Owner's Mailing Address <br />Property Location <br />23796 County Rd H <br />Govt. Lot I <br />'/,, '/4, Section 26 <br />City, State <br />Zip Code <br />Phone Number <br />Shell, WI <br />54871 <br />715-468-2434 <br />(circle one) <br />T40N17; RWEorW <br />11. 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 Union <br />III. Type <br />of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />® New System <br />[] Replacement System <br />❑ TreatmentlHolding 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. 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 <br />❑ Mound s 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 />642 <br />652 <br />90.5 <br />.7 <br />VI. Tank Info <br />Capacity in <br />Gallons <br />Total # ofManufacturer <br />❑ U <br />m Ulu <br />New Tanks Existing Tanks <br />Gallons Units <br />c = J a Q <br />a U in H rn w C7 Ll <br />Septic or Holding Tank <br />x <br />1000 1 Wieser <br />® ❑ ❑ ❑ ❑ <br />Dosing Chamber <br />I I <br />I ❑ ❑ ❑ ❑ ❑ <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 />Plum <br />MP/MPRS Number <br />Business Phone Number <br />Luke Schmitz' <br />_. <br />884121 <br />715468-2434 <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 />Q� Approved ❑ Disapproved Permit Fee a0 I Date Issued Issuing Agent Signature <br />�Yll ❑ Owner Given Reason for Denial $7S ' S 3� " % <br />IX. Conditions of Approval/Reasons for Disapproval <br />E C E � V E <br />ID <br />ni <br />MAY 2 6 2017 <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 12 BLit ied*s in size L� <br />BURNETT COUNTY <br />SBD -6398 (803/14) ZONING <br />