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b4�t�ARTAlF,�.�.G� County <br /> a! Industry Services Division Burnett <br /> 1400 E Washington Ave <br /> P.O. BOX 7162 �Sanitary Permit Number(to be filled in by <br /> Madison,WI 53707-7162 6l $ 7 <br /> Sanitary Permit Application State Transaction Number <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. Shuttleworth Rd. �C / <br /> I. Application Information-Please Print All Information Z 3Z 98 SA u r!ll°. erA Ra <br /> Property Owner's Name Parcel# <br /> Lucas Hetfeld 07-006-2-38-17-20-4 04-000-011000 -tj <br /> Property Owner's Mailing Address Property Location J7 <br /> 23190 Dunham Lake Rd. <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE'/4,SE'/4, Section 20 <br /> Siren,WI 54872 715-789-9369 (circle one) I <br /> T38N R17Eor(P j <br /> II.Type of Building(check all that apply) � Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms U re e- I Subdivision Name <br /> Na <br /> ❑Public/Commercial-Describe Use Block# <br /> Na ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> Pending ® Town of Daniels <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ® New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) I <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑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 ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil t <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑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) 900 Eisa 900 C-1=93.25'C-2=92.25' j <br /> _ 5 <br /> VL Tank Info Capacity in — 1 <br /> Y <br /> Gallons Total #of s 2 �j � y = <br /> Manufacturer N <br /> Gallons Units 0 c Y � 2 -2 2 al <br /> New Tanks Existing Tanks a U y s 3 0, i <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete ® ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ I <br /> VII.Responsibility Statement- 1,the undersigned,assypne responsib''ty for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb Si n ture MP/MPRS Number Business Phone Number <br /> Co Jackson 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 Black Brook Rd.Webster WI 54893 j <br /> VIII.Countqy/De artment Use Only1 <br /> Approved ❑ Disapproved Permit Fee`D V Date Issued Issuing Agent 5ignature I <br /> ❑ Owner Given Reason for Denial $ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D APPROV[D <br /> APR 2 S 2019 D) <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inchegr A V1''1IV�E-I T COUNTY <br /> ZONING <br /> SBD-6398(R03/14) <br />