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6`� r.,rrtiro� County <br /> 1 Safety and Buildings Division Burnett <br /> ON COMPUTE R/SVMWengton Ave., P.O. Box 7162 Sanitary P � be filled in by Co.) <br /> P <br /> S Madison,WI 53707-7162 !� <br /> �4 <br /> Sanitary Permit Application state Transaction Number <br /> C D u.�. P tI i e!q/ <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit Project Address(if different than mailing address) <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 Servies. Personal information you provide may be used for secondary Van Loo Q Rd. /336 <br /> es 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 Parcel# <br /> Rick Kletschka 07-006-2-38-17-34-2 02-009 <br /> 01106 <br /> Property Owner's Mailing Address Property Location <br /> 9311 Elbow Lake Rd. <br /> Govt.Lot `/ S <br /> City,State Zip Code Phone Number NW'/,, NW '/, Section 22 <br /> Siren WI 54872 770-823-7258 T38N; R17E (circle one) <br /> II.Type of Building(check all that apply) Lot# ID <br /> ® 1 or 2 Family Dwelling—Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑ City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> Na R Town of Daniels <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. Y Replacement Y g Replacement Y g Y (explain) <br /> ew S stem ❑R lacement System ❑ Treatment/Holding Tank R lacement Only ❑ Other Modification to Existing System <br /> B. ❑Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration 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 ❑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) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 .7 429 EISA of 440 93.50' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o d o <br /> New Tanks Existing Tanks w o <br /> a U 6% v inn s C7 rs, <br /> Septic or Holding Tank 750 750 1 Wieser Concrete X <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibi'ty for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI s Si re MP/MPRS Number Business Phone Number <br /> Robert Carlson 135655 715-653-2500 <br /> rd <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572 115`x St. Frederic WI 54837 <br /> VIII.Coun /De artment Use Only <br /> Permit Fee Date Issued Issuing Agent Signature <br /> Approved ❑Disapproved pD <br /> ❑Owner Given Reason for Denial $3 7S �� r/` <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> AUG 4 Z016 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in a 11 in <br /> JfflI`TT COUNTY <br /> ZONING <br />