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at='R7 Wr <br />County <br />Industry Services Division <br />Burnett <br />Sanitary Permit Number (to be filled in by Co.) <br />x $ <br />s $ _ <br />1400 E Washington Ave <br />Pt <br />$ <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />vt o <br />�AI " ��-'0 <br />C�0 ct <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 />AIA - <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 />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />William Boldenow <br />07-028-2-40-14-24-505-003-014000 <br />Property Owner's Mailing Address <br />Property Location <br />1219 County road E <br />Govt. Lot 4 3 <br />City, State <br />Zip Code <br />Phone Number <br />'/4, '/4, Section 24 <br />Spooner, WI <br />54801 <br />one) <br />T40N14; RWEorolorrcle <br />IL Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />® 1 or 2 Family Dwelling — Number of Bedrooms J <br />❑ Public/Commercial — Describe Use <br />Block # <br />El City of <br />ElState Owned — Describe Use <br />❑ Village of <br />CSM Number <br />® Town of Scott <br />III. <br />Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />❑ Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />® Other Yodification to Existing System (explain) <br />5v <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 />91292(13233) <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 />Rate(gpdsf) <br />V1. Tank Info <br />Capacity in <br />Gallons <br />Total <br />Gallons <br /># of Manufacturer Uc ti <br />Units <br />Y <br />New Tacks Existing Tanks <br />2 <br />w U i;� in w C7 <br />p. <br />Septic or Holding Tank <br />x $' Q X �.6D0 <br />yi�DD <br />Wieser ® ❑ ❑ ❑ <br />❑ <br />Dosing Chamber <br />❑ ❑ ❑ ❑ <br />❑ <br />VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plum gn <br />MP/MPRS Number <br />Business Phone Number <br />Luke Schmitz <br />884121 <br />715-468-2434 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO Box 160 Shell Lake WI 54871 <br />V II. Coun /De artmmt Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />O <br />Date Issued <br />Issuing Agent Signature <br />❑ Owner Given Reason for Denial <br />$ <br />IX. Conditions of Approval/Reasons for Disapproval <br />�f,w -,� 99a, <br />�/ <br />/ E C� EP <br />`�" <br />/o �J t Gov /- o,e �G dao�/�� i� � ng <br />namcu su wmPacso Pmol or ice sysiem anu submit io cite uounty only on paper not mess than a 1/2 x 11 ine m JUN 2 6 2018 L � <br />SBD -6398 (803/14) BURNETT COUNTY-=� <br />