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- 44 County <br /> 74 Industry Services Division Burnett <br /> ref ' 1400 E Washington Ave <br /> a;., , P.O. Box 7162` Sanitary Permit Number(to be filled in by Co.) <br /> ti, .. 47 Madison,WI 53707-7162 sP-14'092—32 (,431 g <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to theappropriate governmental unit PWTS-032200515 C <br /> is required prior to obtaining a sanitary permit.Note:Applicationforms for state-owned POWTS are submitted b <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 th e Privacy Law,s.1 5.04(1Xm),Stets. 24735 Anchor Inn Rd.,Webster,WI 54893 <br /> I. Application Information-Please Print All information <br /> Property Owner's Name Parcel# <br /> Mark&Judith Boucher 014-2205-02-500 Tax ID#9411 <br /> Property Owner's Mailing Address Property Location <br /> 2732 30t Ave. <br /> Govt.Lot 01 <br /> City.State Zip Code Phone Number '/,> '/, Section 05 <br /> Osceola,WI 54020 (715)417-0303 (circle one) <br /> T38N15; RWEorW <br /> II.Type of Building(check all that apply) 3 Lot# <br /> El1or2 Family Dwelling-Number ofBedrooms 01&02 SubdivisionNane <br /> ❑ Public/Commercial-Describe Use Block# <br /> na 0 City of <br /> ❑ State Owned-Describe Use _ <br /> CSM Number 0 Village of <br /> Vol.3,Pg. 13&Vol.4,Pg. 117 ® Town of La Follette <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System ® Replacement System 0 Treatment/Holding TankReplacement Only 0 Other Modification to Existing Systein(exp lain) <br /> B. ❑ 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 486649 issued 10/16/07 <br /> IV.Type of POWTS System/Component/Device: (Check all that apply) <br /> ❑ Non-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade ® Mound>24 in.of suitable soil 0 Mound<24 in.ofsuitablesoil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 PretreatmentDevice(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> Rate(gpdsf) 450.00sq ft.absoiptionarea 450.00 sq ft.absorptionarea 102.83 at 10"above 102.00' <br /> 450.00 1.0 sand fill/0.5 native soil 900.00 sq.ft.basal arm 1.669.06 sq.ft.basal arm contour <br /> VI.Tank Info Capacity in <br /> Gallons Total #of .0 °" <br /> Manufacturer 0. ,- L., ;, - � ' <br /> Gallons Units :; o g v a _ <br /> New Tanks Existing Tanks p., C. rn m (71 tL 0 a. <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete ® 0 ❑ ❑ ❑ <br /> Dosing Chamber 600 600 1 Wieser Concrete ® 0 0 0 0 <br /> VII.Responsibility Statement-I,the undersigned,assume responsibility for installati n of the POWCS shown on the attached plans. <br /> Plumber's Name(Print) Plumb54.a77 MP/MPRS Number Business Phone Number <br /> Pat Kissack 881072 (715)520-2335 <br /> Plumbers Address(Street,City,State,Zip Code) <br /> W7003 Rappy Lake Rd.,Trego,WI 54888 <br /> V I I .County/Department Use Only <br /> Approved 0 Disapproved Permit Fee cO Date Issneed I r gA nt Si m <br /> J, <br /> 41 0 Owner Given Reason for Denial $376 1!?//2 Z� _ <br /> IX.Conditions of Approval/R ason Disapproval "" ��/ �2 <br /> Meek at( 5,��1._ D V L5 <br /> APR a 5 2022 tUi <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81R tAl i ies in size <br /> goi --Burnett County <br /> SBD-6398(R03/l4) �� Lad Services Department <br /> 3/5 <br />