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oENARTkfiy�, <br />County <br />Industry Services Division <br />Bumett <br />i h I <br />P$ <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 />� <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 fomes 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 />27954 County rd FF <br />L Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />Jon & Luke Schmitz <br />07-036-240-17-26-5 05-001-012000 <br />Property Owner's Mailing Address <br />Property Location <br />23796 County Rd H <br />Govt. Lot 1 <br />'/4, ''/a, 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 />II. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />® 1 or 2 Family Dwelling — Number of Bedrooms <br />❑ Public/Commercial — Describe Use <br />Block # <br />[I City of <br />❑ State Owned — Describe Use <br />❑ Village of <br />CSM Number <br />® Town of Union <br />III. T <br />e of Permit: (Check only one bog on line A. Complete line B if applicable) <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 />642 <br />652 <br />92.5 &91 <br />.7 <br />VI. Tank Info <br />Capacity in <br />Gallons <br />Total # of <br />u <br />Manufacturer U <br />Gallons Units 2 C Y <br />New Tanks Existing Tanks <br />,a <br />a. U <br />Septic or Holding Tank <br />x <br />i000 I Wieser ® ❑ ❑ ❑ <br />❑ <br />Dosing Chamber <br />I I 1 ❑ 1 ❑ I ❑ 1 ❑ <br />1 ❑ <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 />884121 <br />715-468-2434 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO Box 160 Shell Lake WI 54871 <br />Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee d <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />$ 3 7S' ' <br />s 310 — <br />IX. Conditions of Approval/Reasons for Disapproval <br />D E C E � � p E <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 rt£x 11 1Hcbes in size L_f <br />BURNETT COUNTY <br />ZONING <br />SBD -6398 (R03/14) <br />