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Generated by PDFKit.NET Evaluation <br /> County <br /> ermwl.gov Safety and Buildings Division gURNETT <br /> tloLc <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> gs'n Madison,W1 53707.7162 �y �tl r to e e m y49a <br /> Sanitary Permit Application State Tramactionllumber <br /> In accordance with s.Comm.53.21(2),W is.Adm.Code,submission of this form to the appropriate 138 54 1 <br /> governmental unit is required prior to obtaining a sanitary permit Note:Application forms for state-ownedoleo A difteas r f di IIIerent it=mal mg a ress <br /> POWTS are submitted to the Department of Commerce. Personal information you provide may be used for <br /> secondaryes in accordance with the PrivacyLaw,s.15. 1 m Stats. 6502 Nelson d <br /> I. Application Information-Please Print AB Information Parcel# •7 / <br /> Property wners Name 2 032 51312 ©Z uQ' <br /> Burl Johnson Property Location <br /> Govt.LaI <br /> 30799 Hwy 35 <br /> Property Owner's Mailing Address <br /> AW '/., 151,J_ Y., section 12 <br /> city, tate q, one um (circle one) <br /> E or <br /> Danbury WI 54830 (715)656.4527 T 41 N; R 1 r Ci <br /> IL Type of Building(check an that apply) Lot# Subdivision Name <br /> (i I or 2 Family Dwelling-Number of Bedrooms 3 Black# <br /> (' Publid(bmmercial-Describe Use city <br /> (' State Owned-Describe Use <br /> CSM Number (' Village Swiss <br /> (i Township o <br /> Type of Permit: (Check only one box on line A. Compiete line B if appheab <br /> A. <br /> New System (-Replacement System (-Treaimerrt/Holding Tank Replacement Only Other Modificai'on to Existing System <br /> B• r Permit Renewal F Permit Revision F Change of r Permit Tmrnfer m New List Previous Perm Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> F Non-Pressurized In-Ground r Pressurized in-Ground r At-Grade r Mound>24 in of suitable soil D11 Mound 124 in.of suitable soil <br /> (— Holding Tank r Other Dispersal Component(explain) Pretreatment Device(explain) <br /> V.DispersaVrreatment Ares Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(all Dispersal Area Proposed(of) iystem Elevation <br /> 450.00 455.00 450.00 455.00 35.83 <br /> VI.Tank Info Capacity in Total Number Manufacturer c <br /> Gallons Gallons of Units ' U° ❑p 'u k <br /> ew Tacks waling <br /> U <br /> TNI <br /> Scptic or Holding Task 1000 1600 1 Skaw Pre-Cast <br /> nosing Chamber 600 r r r r r <br /> VII.Responsibility Statement- L the undersigned,assume mspomibi ity for installation of the POWTS shown on the aft,ehed plans. <br /> Plumber's Name(Print) ;pbcrl s Sire MP/MFRS Number Bu iness Phone Number <br /> Ross Tollander �� 851954 (7 566-8070 <br /> zero rs ess eet, dy, tate, <br /> 27220Jamison Rd,Webster,WI 54893 <br /> VIII.Comity/Department Use Only <br /> Approved (- Disapproved Sanitary Permit Fee(includes Growdwater Dffie Issued Iss ' en[Si a(No Stamps) <br /> Surcharge Fee) �r '9 <br /> F Owner Given Reason for Denial # <br /> IX.Conditions of Approval/Reasous for Disapproval <br /> Affach complete pns(to the County only)for the ayskm on paper not sa them 1 x 11 inch"in s¢ <br /> Click Ism t0AirtWckP0RKILNET01;C) <br />