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Salety and Buildings Division County '�__//..,,�� <br /> ` 201 W. Washington Ave.,P.O.Box 7162 ,�V✓VICW <br /> �s������ Madison,W1 53707--7162 Sanitary Penn it Number(to be filled in by C'o.1 <br /> Department of Commerce (608)266-3151 Sz <br /> Sanitary Permit Application Stale Plan 11) Nm"her Uj <br /> In accord with Comm 83.21_Wis.Adm.Code,personal iniounation you provide �- <br /> maybeusedforse:ondan purposes Privacy taw,sl504(I)(m) Project Addresst different than mailing address) <br /> i <br /> 1324 West�oint Rd. ` ,JV` <br /> I. Application Information—Please Print All Information .�}- rte <br /> C ll ���� 028 -4I25 02000 <br /> Property Owner s Name Parcel Ni Lot U Block tl <br /> Bruce & Laura Bray (Tall Timbers Resort) Govt. 3 <br /> Property Owner's Mailing Address Property I vcation <br /> N4811 Rainbow Drive <br /> Section 25 <br /> � %, <br /> City,State Zip Cade Phone Number _--- <br /> /,. <br /> Spooner WI 5480140 N 1214(c�rdoone) <br /> I1.Type of Building(check all that apply) <br /> ❑J I ore Family Dwelling—Number of Bedrooms 2 Subdivision Name CSM Number <br /> ❑Public/Commercial—Describe Use <br /> ❑Slate Owned—Describe Use ❑City ❑Village '❑)osvnship of Scott <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. <br /> ❑ New SN stem '❑ Replacement System ❑ lYcalmenl/I folding Tank Replacement Only 11 Other Modification to ILeis6ng System <br /> B - list Previous Permit Number and Date Issued <br /> ❑ Permit lienewal ❑ Permit Revision ❑ Change of ❑PermitTmnslcr Rr Ncw <br /> Before Expiration Number Owner <br /> IV.Tv a of PONVfS System: Check all that apply) <br /> '❑ Non-Pressurised In-Ground ❑ Mound 124 inof suitable soil ❑ Mound 124 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Pllcr ❑ <br /> Constructed Weiland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peal Piller ❑ Aerobic l recurrent Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Melia Filter ❑Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Ofher(explain) <br /> N.Dispersal/Ifireatiment Area Information: <br /> Design Plow(gpd) Design Soil Application Rale(gti Dispersal Area Recoiled(s'f) Dis'persal Area Proposed(st) System Plevation <br /> 300 .5 600 600 97.5/96.5 <br /> NT'I Info Capacity in 'total Number Manufacturer Prefab Site Steel Iiher Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New fixistinp <br /> I asks "l asks <br /> s`(„i`erlleldo, Iark 1000 1000 1 AK Industries x <br /> nrrenio rrcaimem ens <br /> Unsinp Chanihcr <br /> b'l1.Responsibility Statement- 1,the undersigned,assume re. onsibility for installation of the PORTS shown on the attached plans. <br /> Plumber's Name(Print) P umb 's Signature MPM116 Number Business Phone Number <br /> Kelly Ferguson , 224069 715-635-2887 <br /> _ _ <br /> Plumber',Address(Street,City State_Zip(lode) <br /> W9502 Dock Lake Rd. Spooner WI 54801 <br /> VIII.Count y/Dc artment Use Only <br /> Y Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Dale Issued Issu A it Signat - o Stamps) <br /> Surcharge Fcet <br /> ❑ Osvncr Given Reason(or Denial J <br /> IR Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the('runty only)for rhe system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />