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comme/mfce.wi.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnell <br /> ismIs�n Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co_) <br /> Departmetst of Commerce -5Z/ 058 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental 1$3 &OLO <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- 25351 Rolling Green Rd. <br /> 1. Application Information-rlease Print All Information, <br /> Property Owner's Name _ Parcel N <br /> Lois Country Cupboard 6>2 3/27 02 7o <br /> Property Owner's Mailing Additess Property Location <br /> 25351 Rolling Green Rd. <br /> Govt.Lot <br /> City,State Zip Code Phone Number NE Y.,SE 'A Section 27 <br /> Spooner WI 54801 715-635.3084 (check one) <br /> IL Type of Building(check all that apply) Lot N T 39 N, R 14 ❑E EJW <br /> F-11 or 2 Family Dwelling-Number of Bedrooms 40 acres Subdivision Name <br /> Block# <br /> Public/Commercial-Describe Use catering kitchen <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ❑✓ Town of Rusk <br /> Ill.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A_ ❑ New System ❑ Replacement ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> System <br /> —ToB. F1 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.Type of POWTS S stem/Com onent/Device: Check all that a I <br /> ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade Mound>24 in.of suitable soil E] 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(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 400 <br /> V1.Tank In Capacity in Total H of Manufacturer Material <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank 2000 2000 1 Wieser Prefab Concrete <br /> Dosing Chamber <br /> V II.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature PMP <br /> RS Number Business Phone Number <br /> Rick Brownff- 231251 419-0739 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 319 Badger Rd.Rice Lake WI 54868 <br /> VIII.County/Department Use Only <br /> _VApproved _ Disapproved Permit Fee Dale <br /> Issued Issuin nt Signature <br /> Owner Given Reason for Denial permit <br /> ✓✓✓2C', 111 3vne O� <br /> Ir.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 Vz x I l inches in size <br /> SBD-6398(R.01/07)Valid thou 01/09 <br />