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cArtrCounty <br /> 4,.,,o7- 4/.0c. Industry Services Division Burnett <br /> 147( . K 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 141•1"-a0 <br /> 1 <br /> \S\ F. Madison,WI 53707-7162 flN a0-b9 <br /> \- r e Sr- -4/7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 4234'A(0 <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 Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. 8924 Black Brook Rd. <br /> I. Application Infarmation—Please Print All Information <br /> Property Owner's Name Parcel# �'O� 0 <br /> Donald Fleischhacker 07-016-2-39-17-14-3 03-000-011000 <br /> Property Owner's Mailing Address Property Location 1 <br /> IP.O.Box 363 <br /> Govt.Lot <br /> City,State Zip Code Phone Number SW''/,SW'A, Section 14 <br /> Webster,WI 54893 circle one) i <br /> • <br /> T39N ; R 17 <br /> II.Type of Building(check all that apply) Lot# <br /> Z 1 or 2 Family Dwelling—Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# <br /> 0 City of <br /> ❑State Owned—Describe Use 0 Village of <br /> CSM Number <br /> Na Z Town of Lincoln <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ® Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner moi_ 0 20Q2, t YO9 tO <br /> IV. Type of POWTS System/Component/Device: (Check all that apply) c-�c� ! T <br /> ® Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank ®Other Dispersal Component(explain) Cony.Lift 0 Pretreatment Device(explain) I <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 900 EISA 900 98.08' <br /> .5 _____ <br /> VI.Tank Info Capacity in <br /> .o <br /> Gallons Total #of Manufacturer h U r' <br /> New Tanks Existing Tanks Gallons Units a U ii5 v, via.C7 ], <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete ® 0 0 0 0 <br /> Dosing Chamber 750 750 1 Wieser Concrete ® 0 0 0 0 <br /> VII.Responsibility Statement- I,the undersigned, sume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu b 's Si aturr7 �r6������ MP/MPRS Number Business Phone Number <br /> Dayton Daniels / /✓( �'`�/ , 007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 326 Siren WI 54872 <br /> VIII.Coun /De i artment Use Onl _ <br /> VV00 <br /> pproved 0 Disapproved Permit Fge Date�supsuing gent Signa e / / <br /> 0 Owner Given Reason for Denial $.7TH JC �� <br /> IX.Conditions of Approval/Reasons for Disapproval if <br /> Urar� . s) ... Mot. E of cover. ' C E O V E !1 <br /> 11): adt Rbw-rs it bt 4tioiatelowett per SPs. 3u. <br /> lopwt Attt fach to complete plans for cd 4(the system and submit to the County only on paper not less than 8 1/2 x 11 h:i, i size <br /> Burnett County <br /> SBD-6398(R03/14) Land Services Department <br /> /_s V-fi. Z27.---rD, -4K7-,� <br />