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County <br /> r4rrion <br /> Q Industry Services Division W4� COMPUTER/SCANNED <br /> �a 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> <i P.O. Box 7162 <br /> ' _p S "' Madison,WI 53707-7162 i <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 C m u.� Xea%e w <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to project Address(if different than mailing address) <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. Same <br /> I. Application Information—Please Print All Information <br /> a���6o <br /> Property Owner's Name Parcel# <br /> Richard Ellingsworth Trust 07-014-2-38-15-05-5 15-815-013000 <br /> Property Owner's Mailing Address Property Location <br /> 24654 Larrabee Subdivision Rd. <br /> Govt.Lot 4 <br /> City,State Zip Code Phone Number '/., '/4, Section 5 <br /> Webster,Wl 54893 715-349-2333 (circle one) <br /> T38N R15EorW <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling—Number of Bedrooms E 12.6'Lot 1 of Viola LK Sub. Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# �oL <br /> ❑ City of <br /> ❑State Owned—Describe Use El Village of <br /> CSM Number <br /> Lot 1 Csm Vol.2 Pg.138 ® Town of LaFollette <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber 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 Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 Rate(gpdsf) Na Na Na <br /> Na <br /> VI.Tank Info Capacity in <br /> Gallons Total #of Manufacturer o U <br /> Gallons Units o Y 2 n <br /> New Tanks Existing Tanks Q U 1 <br /> Septic or Holding Tank 2000 2000 1 Wieser Concrete Products ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ 1 ❑ 1 ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned su re ility for'nstallafron of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pl is i e 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.County/Department Use Only <br /> ® Approved ❑ Disapproved Permit Fee <br /> r O Date Issued Issuing Agent SignatureAA <br /> Zep� <br /> ❑ Owner Given Reason for Denial $ J 7 J' ' 'OZ 9'�s <br /> IX.Conditions of Approval/Reasons for Disapproval ECENE <br /> IJUL 2 9 Z015 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In a 11 h size <br /> BURNETT COUNTY <br /> ZONING <br />