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UN I:UMt U i LK/5UANNLU <br /> eommerce.wi.gov Safety and Buildings Division County <br /> 201 W. Washington Ave.,P.O.Box 7162 Burnett <br /> MC seo n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> ct�t,n>erce 49 o 49 7 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm. 83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental -_Or� <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Spirit Lake Access Rd. <br /> purposes in accordance with the Privacy Law,s. 15,04 1 (m),Stats. <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Boyd Dufour f: ; 034-9025-01400 <br /> Property Owner's Mailing Address ( Property Location <br /> 21845 Spirit lake Access Rd. <br /> Govt.Lot 2 <br /> City,State Zip Code Phone Number Section 12 <br /> Frederic Wi 54837 715-327-8809 (circle one) <br /> T37N; R18Ei6 <br /> II.Type of Building(check all that apply) Lot# <br /> l or 2 Family Dwelling-Number of Bedrooms 2 4+5 Subdivision Name <br /> Block# Lots 4+5 of Loafers Bend Sub. <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ❑Town of Trade lake <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> ` . ❑ New System ❑ Replament System Tank Replacement Only Other Modification to Existing System(explain) <br /> ) <br /> B. El Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑PList Previous Permit Number and Date Issued <br /> ermit Transfer to New 7457,0 821/79 <br /> Before Expiration 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) Pump Tank Replacement ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 .7 428 432 existing Approx. 100.00' <br /> VI.Tank Info Capacity in 'Total #of Manufacturer <br /> Gallons Gallons Units a o b v <br /> New Tanks Existing Tanks w e d a <br /> Septic or Holding Tank 750 750 1 Wieser Concrete x <br /> Dosing Chamber 750 750 1 Wieser Concrete x <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumbers-Signature ' 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[6 Street Frederic WI 54837 <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved Permit Fee DateIssuing Age atu <br /> Issued re <br /> ❑ Owner Given Reason for Denial $ �� M ZZf 07 <br /> IX.Conditions of Approval/Reasons for Disapproval p M,p IANI< <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/1 x 11 inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />