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r rcry County <br /> Industry Services Division Burnett <br /> ;a/ p S � 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> p P.O. Box 7162 r/ <br /> Madison,WI 53707-7162 J � / <br /> R <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 <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. Same <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Emma Jean Hinrichs 07-034-2-37-18-14-102-000-0110000 <br /> Property Owner's Mailing Address Property Location <br /> 11117 Whispering Pines Rd. <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW'/4,NE%, Section 14 <br /> Frederic, WI 54837 (gurleone) <br /> T37N Rl8Eo <br /> H.Type of Building(check all that apply) / Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms /"e e- (3 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> El City of <br /> ❑State Owned-Describe Use <br /> IC <br /> SMNumber ElVillage of <br /> ® Town of Trade Lake <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 S stem/Com nenVDevice: (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 /> Resign Flow(gpd) Design Soil Application Dispersal Area Required(sin) Dispersal Area Proposed(sin) System Elevation <br /> 300 esr, Rate(gpdsf) Na Na Na <br /> Na <br /> VI.Tank Info Capacity in <br /> a <br /> Gallons Total #of <br /> E o <br /> New Tanks Existing Tanks Gallons Units Manufacturer Y <br /> Septic or Holding Tank 2000 2000 1 Wieser Concrete ® ❑ ❑ ❑ ❑ <br /> WLP2000MR <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement-1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Les gn MP/MPRS Number Business Phone Number <br /> Robert Carlson 135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572 115°i Street Frederic WI 54837 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit <br /> -7Fee Date Issued Issuing Agent Sign <br /> ❑ Owner Given Reason for Denial $ 3/S• p 'z�p I(� <br /> IX.Conditions of Approval/Reasons for Disapproval Lq U ly �'U <br /> AUG 2 4 2016 <br /> Anaeb to complete plass for the system and submit to the County only on paper not less than 8 l2 a 11 is R in s <br /> ONING <br />