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- -- ---'- -'- ----✓--_.._ -.... .............. ..... <br />County <br />Industry Services Division <br />Burnett <br />1 :K{ <br />1400 E Washington Ave <br />P.O. Box 7162 <br />Sanitary Permit Number (to be filled in by Co.) <br />a/ <br />Madison, WI 53707-7162 <br />AL <br />V� V 1 �✓� <br />Sanitary Permit Application <br />State Transaction Number <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit <br />3142163 <br />is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to <br />Project Address (if different than mailing address) <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />purposes in accordance with the Privacy Law, s. 15.04(1)(m , Stats. <br />27283 Devils take Rd <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />David & Laura Fitzpatirie, <br />07-020-2-40-16-34-5 15-090-013000 <br />Property Owner's Mailing Address <br />Property Location <br />120 Dottie Court <br />Govt. Lot 2 <br />'/4, '/., Section 34 <br />City, State <br />Zip Code <br />Phone Number <br />West salem, WI <br />54669 <br />(circle one) <br />T40NI6; RWEorW <br />II. Type of Building (check all that apply) <br />® <br />Lot # <br />12-13 <br />Subdivision Name <br />1 or 2 Family Dwelling — Number of Bedrooms <br />Colter Sub <br />Block # <br />❑ Public/Commercial — Describe Use <br />ElState Owned — Describe Use <br />1 <br />❑ City of <br />❑ Village of <br />CSM Number <br />® Town of Oakland <br />III. <br />pe of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />❑ New System <br />® Replacement System <br />❑ Treatment/HoldingR <br />Tank Replacement Only <br />❑Other Modification to Existing System (explain) <br />B. <br />❑Permit Renewal <br />El Permit Revision <br />Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />Owner <br />1 NV $-7Y <br />IV. <br />Type of POWTS System/Component/Device: (Check all that apply) <br />❑ Non -Pressurized In -Ground ❑ Pressurized In -Ground j At -Grade ® Mound > 24 in. of suitable soil ! Mound < 24 in. of suitable soil <br />❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application <br />Dispersal Area Required (st) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />600 <br />Rate(gpdsf) <br />600 <br />600 <br />99.25 <br />1 <br />VI. Tank Info <br />Capacity in <br />Gallons <br />Total # of <br />Gallons Units <br />Manufacturer <br />b <br />m o <br />w ❑ y, <br />New Tanks Existing Tanks <br />Septic or Holding Tank <br />x <br />1250 1 <br />Wieser <br />® ❑ ❑ <br />❑ <br />Dosing Chamber <br />x <br />750 1 1 <br />Wieser <br />® ❑ <br />❑ <br />❑ <br />VIL Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber' re <br />MP/MPRS Number <br />Business Phone Number <br />Luke Schmitz <br />884121 <br />715468-2434 <br />Plumber's Address (Street, City, State, Zip Code) <br />PO Box 160 Shell Lake WI 54871 <br />VIII. County/Department Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />0 <br />Date Issued <br />Issuing Agent Signature <br />C1 Owner Given Reason for Denial <br />$ 3 %S <br />0 d ' a•0 <br />J, <br />IX. Conditions of Approval/Reasons for Disapproval <br />IPPROVED ECEWE <br />Att—h to rn <br />--%v -y vu Napo nut mm luau O 1/lL3 11 i■ LI nes In size I - / <br />I / L�!/ <br />BURNETT COUNTY <br />SBD -6398 (R03/14) ZONING <br />