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`a,‘n r11/x County <br /> Industry Services Division Burnett <br /> -~'S p 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 <br /> -x-123 <br /> , Madison, WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number 0 6-1.4,,O <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. N/A 6I. Application Information-Please Print All Information -z-170r«y i �S, F� <br /> Property Owner's Name Parcel# 35,57/ <br /> Thomas and Mary Heenan 07-012-2-40-15-13-5 15-124-090500 <br /> Property Owner's Mailing Address Property Location <br /> 3457 Kilcare CRT <br /> Govt.Lot 2 <br /> City,State Zip Code Phone Number '/4, /., Section 13 <br /> Danbury,WI 54830 (circle one) <br /> T40N ; R15EorW <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name <br /> Deer Lodge VV ADD <br /> ❑Public/Commercial-Describe Use Block# <br /> 0 City of <br /> ❑State Owned-Describe Use 0 Village of <br /> CSM Number <br /> 4982 Vol 28 P 71 ® Town of Jackson <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ® New System 0 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 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <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 0 Other Dispersal Component(explain) 0 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 /> 450 Rate(gpdsf) 643 652 94 <br /> .7 <br /> VI.Tank Info Capacity in B <br /> c o <br /> Gallons Total #of Manufacturer ed Q U tpp ti <br /> New Tanks Existing Tanks Gallons Units a.U iin rr'i, cn 'w C., r1. <br /> Septic or Holding Tank 1000 1000 1 Wieser ® 0 0 0 0 <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assume spons' lity installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's S e MP/MPRS Number Business Phone Number <br /> Dan Burch 253808 715.416.1642 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1118N Front Street Spooner WI 54801 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee Date Issued Issuin Agem to e <br /> ertilit...M_______ <br /> 0 Owner Given Reason for Denial $ 3 757 5..-7 ii•2-1 ' M <br /> IX.Conditions of Approval/Reasons for Disapproval D l� © t E v , <br /> e,,S.•`,Y 13 20/1 <br /> Attach to complete plans for the system and submit to the County only on paper not less than f 1/21 1FtiIn size <br /> 042,.. Burnett County <br /> Cl 3t, 3�� Land Services Department <br /> SBD-6398(R03/14) C.�z- a�g 3Sp°� <br />