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County <br /> Commermwl.gov Safety and Buildings Division BURNET] i <br /> tic, <br /> a W.Washington Ave.,P.O.Box 7162 Sanitary mtVOns'n Madison,WI 53707-7162 �"nt er toe e m y ,o.201 rnMof nmmbria �S <br /> ��5 3 <br /> Sanitary Permit Application Stt <br /> ae Tramertion Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate 13 8 71+ <br /> govemmernal unit is required prior to obtaining a sanitary permit Note:Application forms for state-owned ProjectAddress r di erent than mat mg address <br /> POWTS are submitted to the Department of Commerce. Personal information you provide may be used for 24745 VIOLA LAKE RD. <br /> secondary purposes in accordance with the Privacy Law,s.15. 1 m,Stals. <br /> 1. Application Information-Please Print All Information Parcel# <br /> Property Owners Name <br /> ROLAND SALZMAN Property Locato <br /> W Govt.LM I <br /> Property n s Mailing Address <br /> 24745 VIOLA LAKE RD. Y,, '/. section 6 <br /> City,State Eip Code Phone Number (circle one) <br /> c EorW <br /> WEBSTER WI 54893 (715)349-5248 T 38 N; R ;a <br /> R.Type of Building(check all that apply) Lot# Subdivision Nam <br /> ',i I or 2 Family Dwelling-Number of Bedrooms 3 Block# _ <br /> Public/Commercial-Describe Use City <br /> (' State Owned-Describe Use CSM Number Village LA FOLLET$ <br /> !i Tawruhip t <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. (�New System ,i Replacement System .,Trea menVHolding Tank Replacement Only C Other Modifi'dion to Existing System <br /> B. Permit Renewal Permit Revision Change of Permit Transfer to New Lis[Previous P it Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> Non-Pressurized In-Ground Pressurized In-Ground At-Grade I Mound>24 inof suitable soil Mound<24 in.of suitable soil <br /> Holding Tank Other Dispersal Component(explain) Preheatmem Device(explain <br /> V.DlspersaVfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 45000 455.00 1 450.00 455.00 98.42 <br /> VI.Tank Info Capacity in Total Number Manufacturer °o v <br /> Gallons Gallons of Units U <br /> Ncw Lxrsung U rn i m w C7 y <br /> Tanks Tanks <br /> Swti..,noldmg T.ak 1000 1600 1 Skaw Pre-Cast <br /> Dosing Chamber <br /> V 11.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the at ached plans. <br /> Plumbers Name(Print) PIu 's Sire I MP/MPRS Number B siness Phone Number <br /> ROSS TOLLANDER 851954 ( 15)866-8070 <br /> Plumber's Address(Street,City,State,Zip e) <br /> 27220 JAMISON RD,WEBSTER,WI 54893 <br /> Viii.County/Department Use Only <br /> a Approved Disapproved Sanitary Permit Fee(includes a a Issued G oundwater Dh su' Agent Signature(Nm Stamps) <br /> _ Surcharge Fee) '�f Y� r <br /> Owner Given Reason for Denial 43M.U0 / � / <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Ataeh ramp ere plias(to tae C oaaly.aly)fort the-yawn oa paper ant kas m 8n <br /> 1 me n m e'e <br /> BURN TT COUNTY <br /> _.. _. .._...OLC+ ZONING <br />