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commerce.vA.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> isco ns i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co) <br /> Depn of Conane� 5511 q 9 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this forth to the appropriate governmental <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) (51 <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 1 m,Stats. i n <br /> L s <br /> Application Information—Please Print All Information b G/1. l/4.1� a <br /> Property Owner's Name parcel# Q' <br /> Douglas Mcivor A,A35aga 070322411518201000011300 / <br /> Property Owner's Mailing Address Property Location <br /> 1510 N Page St <br /> Gov[.Lot <br /> City,State Zip Code Phone Number NE �/�y., Section 18 <br /> Stoughton,WI 53589 (circle one) <br /> II.Type of Building(check all that apply) Lot# T 41N; R 15 W <br /> ® t or 2 Family Dwelling—Number of Bedrooms 3 19 Subdivision Name <br /> Public/Commereial—Describe Use Block# <br /> Cityof <br /> ❑ State Owned—Describe Use CSM Number ❑ Village of <br /> V. 3 I ® Town of Swiss <br /> 111.Type of Permit: (Check only one boa on line A. Complete line B if applicable) _ _ —�l <br /> A. New System0 Replacement LJ TreatmentMolding 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 <br /> Expiration <br /> IV. a of POWTS S steaf/Com onent/Device: Check all that a I <br /> Non-Passurized In-Ground Pressurized In-Ground A[-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) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 .6 450 450 99.50 <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o $ v <br /> New Tanks Existing Tanks y <br /> ri 0 ti w C7 L <br /> Septic or Holding Tank 1000 1000 1 Wieser N El El I L1 <br /> Dosing Chamber 600 600 1 Wieser <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign MP/MPRS Number Business Phone Number <br /> Travis Butterfield 652879 (715)634-8176 <br /> Plumber's Address(Street,City,State,Z406 e <br /> 14346 W State Road 77 Hayward,WI 54843 <br /> VIII.Coun /De artment Use Only <br /> Approved I ❑ Disapproved Permit FeeDate Issued Issuing Agent Signature <br /> ElOwner Given Reason for Denial $��� )0—)3-1 I <br /> DL Conditions of Approval/Bessons for Disapproval <br /> ftOCT 13 2011 <br /> BURNEUCOL <br /> Attach to complete plans for the system mod submit to the County only on paper not less than 8 in x It inches in size ZONING <br />