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commerceml.gov Safety and Buildings Division County <br /> a 201 W.Washington Ave.,P.O.Box 7162 VYn6 <br /> isconsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Department of Commerce 558 256,5 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this to=to the appropriate governmental ,Z#_5e118 <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(I)m,Stats. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> West Marshland Hunting Club-Neil Hokanson 07-040-239.19.21.4 01.000-011000 <br /> Property Owner's Mailing Address Property Location <br /> 14224 Bloom Rd act(07 a�7/s at Govt.Lot <br /> City,State Z Zip Code Phone Number NE '/,, SE '/., Section 21 <br /> Grantsburg,Wl r(,I' wlxc� 54840 jx 715354-7080 (check One) <br /> 11.Type of Building(check all that apply) --����co7 Lot# T 39 N' R 18 ❑E ❑v W <br /> F/11 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ❑✓ Tovmof West Marshland <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System LJ Replacement ❑✓ Treatmenh'Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> System <br /> B. Permit Permit Revision Change of Permit Transfer to List Previous Permit Number and Date Issued <br /> Renewal Before Plumber New Owner p <br /> Expiration /485 11/2/ Q3 <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that a I <br /> 0. <br /> ❑ Non-Pressurized In-Ground Pressurized In-Ground ❑At-Grade ✓ Mound>24 in.of suitable soil LJ 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) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer Material <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank 1000 1000 1000 1 Wieser Prefab Concrete <br /> Dosing Chamber 600 600 1 1 Wieser Prefab Concrete <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I MP/MPRS Number Business Phone Number <br /> Dayton R Daniels 1#007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 326 Siren,WI 54872 <br /> VI .Count /De artment Use Onl <br /> Approved _ Disapproved Permit Fee Date Issued Issuing ignature <br /> _Owner Given Reason for Denial $ 75::Co452;W201?_ <br /> IX.Conditions of Approval/Reasons for Disapproval J�x. <br /> 'eGG K GR sr/&G rer 9XS' wj MOUNd <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x Il inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />