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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> Asconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> De artment of Commerce (608)266-3151 479S71 <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(l)(m) Project Address(if different than mailing address) <br /> 1. Application Information-Please Print All Information 8743 Waldora Road <br /> Property Owner's Name Parcel# Lot# Block# <br /> Niles Peterson 006-2423-01300 <br /> Property Owner's Mailing Address Property Location <br /> 23789 Peterson Road N W'/., NE Y., Section 23 <br /> City,State Zip Code Phone Number <br /> Siren WI <br /> 54872 (715349-2884 T 38 N; R17W (circle one) <br /> 4c,or <br /> of Building(check all that apply) <br /> V'`'or 2 Family Dwelling-Number of Bedrooms 3 Bedrooms Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use Csm# <br /> El State Owned-Describe Use ❑City_❑Village Township of Daniels <br /> III.Type of Permit: (Check only one boa on line A. Complete line B if applicable) <br /> A. ❑New System 1}Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> JO Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Weiland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Send Filter ❑ <br /> Recirculating Synthetic Media Filter Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.DispersalfIrreatment Area Information: 11'Standard Bio-Diffuser Leaching Chambers <br /> Design Flow(gpd) Design Soil Application Rate(gpdsI) I Dispersal Arm Required(st) Dispersal Area Proposed(at) I System Elevation <br /> ly, 450 .5 900 sq.It EISA=31.1 sq.It x 30=933 Cell#I=92.80 Cell#2=91.20 <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New I Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete x <br /> Aerobic Trestme t Unit <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) PI 's Sign MP/MPRS Number Business Phone Number <br /> Robert Carlson # 135655 (715)653-2500 <br /> Plumber's Address(Street,City,State,Zip C e <br /> 3572 1151°Street Frederic Wl 54837 <br /> VII <br /> County/Department Use Out <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issui or Sign (No Stamps) <br /> Surcharge Fee) F,O rfp <br /> ❑ Owner Given Reason for Denial •/ J ��-J' <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plum(to the Coanty only)for the system on paper not less than 912 111 inches in sill <br /> SBD-6398 (R. 01/03) <br />