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commerce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> isconsin Madison,W1537077162 Sanitary Permit Number(to be filled in by CoI <br /> Delaartmeret of Commerce .5Z/057 f 1 1 <br /> Sanitary Permit Application State Transaction Number W <br /> In accordance with s.Comm.83 2](2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sarotary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04 I m,Stats. 25351 Rolling Green Rd. <br /> I. Application Information-Please Print All Information - <br /> Property Owner's Name Parcel# 024312702.700 <br /> Dale B Lois Stellrecht OP060-01100p <br /> Property Owner's Mailing Address Property Location <br /> 25351 Rolling Green Rd. <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE Y.,SE V., Section 27 <br /> Spooner WI 54801 715.6353084 (Check one) <br /> II.Type of Building(check all that apply) Lot# <br /> T39 N; R 14 ❑E ❑� W <br /> 21 or 2 Family Dwelling-Number of Bedrooms 2 40 Acres Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use Catering <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ village of <br /> ❑✓ Town of Rusk <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' New System ✓ Replacement ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) <br /> System <br /> B. Permit ❑ Permit Revision 1:1Change of Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV. <br /> ! e of POWTS S stem/Com onent(Device: Check all that a 1 <br /> ✓ Non-Pressurized In-Ground ❑ Pressurized In-Ground At-GradeLl Mound 124 in.of suitable soil ❑Mound 124 inof suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) []Pretreatment Device(explain) <br /> V.Dis emalrrreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rale(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> (L(S p .7 lfl y 3 16.y) 89.0 <br /> VI.Tank Info Capacity in Total #of Manufacturer Material <br /> Gallons Gallons Units <br /> New Tanks Existing Talcs <br /> Septic or Holding Tank IOOO 1000 1 Wieser Prefab Concrete <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 Signal aMP/MPRS Number Business Phone Number <br /> Rick Brown 231251 419-0739 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 319 Badger Rd.Rice Lake WI 54868 <br /> VII Count Ne artment Use Only <br /> Approved _ Disapproved Permit Fee Date Issued Issuing Signature <br /> _Owner Given Reason for Denial $ <br /> IX.Conditions of AppmvaVReamngior )isapprosal <br /> uuie: ')1v1R. AxiM(xt Ca/e Quer $otll 461(- lane- k1(i0 <br /> 1d^cNrv•G CAAmt$615'. <br /> Attach to eomplea plain for the system and submit to the County noly on paper not less theirs V2.11 inches in size <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />