Laserfiche WebLink
Safety and Buildings Division County g� <br /> Vi <br /> W201 W. Washington Ave.,P.O.Box 7162 UYYIseons�n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce (608)266-3151 2� <br /> Sanitary Permit Application State Plan I.U.NNumbers <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide ✓r^"r e-� 4f n �G) <br /> maybe used for secondary purposes Privacy Law,sl5.04(1)(m) P2rgjgc)1 ddre$s(if differgndt than mailing address) <br /> `V McKenzie Ft <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# Lot 4 Block 4 <br /> Stephen Roman pp_pa6_,1-910ly-0A-y-01_oac_9000 <br /> Property Owner's Mailing Address Property Location '9Z I- = -19W40 <br /> 127 Cty Rd. E <br /> NE ,� SE A. Section 2 <br /> City,State Zip Cade Phone Number <br /> Spooner WI 54801T 40 N; R 1 4(circle one) <br /> r <br /> 11.Type of Building(check all that apply) ./ <br /> ❑+ I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> Public/Commercial-Describe Use <br /> ❑Stale Owned-Describe Use []City [3Village ']township of SCOtf <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> '❑ New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only [3 Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Fxpiration Plumber Owner <br /> IV.Type of POWTS System: Check all that apply) <br /> ❑' Non-Pressurized In-Ground ❑ Mound>24 im of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber 13 Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(st) Dispersal Area Proposed(so System Elevation <br /> 450 .7 643 660 98. <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New I Existlag <br /> Tanks Tanks <br /> Septic or Holding'raak 1 QQO 1000 1 Wieser X <br /> Aerobic Treatment 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) Qlu ber's Signatur MP/MPRS Number Business Phone Number <br /> Kelly Ferguson 224069 715-635-2887 <br /> Plumber's Address(Street,City,State,Zip Coe) <br /> W9502 Dock Lake Rd. Spooner W 54 01 <br /> VIII.Count /De Department Use Only 157 15�:7 <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Ua[e Issued Issui gen[Signat (No Stamps) <br /> Surcharge Fee) Cop <br /> El Owner Owner Given Reason for Denial J09 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 812 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />