Laserfiche WebLink
Industry Services Division County <br /> 4 4822 Madison Yards Way BURNETT <br /> ' 'it Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 *—a2/ —a 4.5- <br /> �' Madison,W153707-7162 �,:�)-7 �$3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit / <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary GASLYN CREEK ROAD <br /> purposes in accordance with the Privacy Law,s.15.04(l)(m),Stats. <br /> I.Application Information-Please Print Ali Information ?-(0 )5 <br /> Property Owner's Name Parcel# -35S70 <br /> CRAIG & PAM BOHN 07-024-2-39-14-2 04-000 011000 <br /> Property Owner's Mailing Address Property Location <br /> 2675 GASLYN CREEK Govt_Lot PART OF <br /> City,State Zip Code Phone Number <br /> WEBSTER WI 154893 320 630 7002 SE ,,4, �,4, s <br /> IL Type of Building(check all that apph) Lot# Tff <br /> 39 R 1'4W E or W <br /> Ell or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> Oublic/Commercial-Describe Use <br /> I of <br /> fate Owned-Describe Use CSM Number illage of <br /> roam of RUSK <br /> M.Type of POWTS Permit:(Cheek either"New"o:"Replacement"and other applicable on But A. Check one box on One B.Complete line C it <br /> applicable.) <br /> A. aew System aeptacemeut System [] ther Modifit ation to Existing System(explain) tional Pretreatment Unit(explain) <br /> $' [:]Holding Tank aIn-Ground at-GradeMound Individual Site Design Other Type(explain) <br /> (conventional} <br /> C. ❑Renewal Before DRevision hange of Plumber Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration I r <br /> IV.Diispersavirreatmeat Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Disperavl Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 .7 1432 1450 1>=92.6' <=93.6' <br /> capacity in Tod.. #of Manufacturer <br /> Tank Information Gallons Gollm Units ° <br /> New Tacks Eustiug Tacks c <br /> 7 <br /> a U <br /> septic or Holding Tank 700/300 1000 1 SKALW MNAST PARTWOONED ✓ <br /> Dosing Chamber Q <br /> ,9R, <br /> V.Responsibility Statement-I,the tmadersigned,gloom reespo►ndbil1ty for Ylstalladon of ft I TS shown on the attached plats. <br /> Plumber's Name(Print) PI Ri CnneAVAT10 MP/MPRS Number Business Phone Number <br /> Mel Ferguson dba $ p MPRS 224879 <br /> 11-1b Fri <br /> Plumber's Address(Street,City,State,Zip P6&ER,WI 54801 <br /> 2 <br /> Vl.Coup ent Use <br /> Approved ❑Disapproved Only <br /> Permit Fce� ' Date Lmaed Signature <br /> 17 Owner Given Reason 1br Denial 5 7`� <br /> Conditions of Approval/Reasons for Ditappwvsi D <br /> AUG 10 2021 <br /> Burnett County <br /> Land Services Department <br /> Attach to complete plans for the system and submit to the County only on paper not less than A 1/2 111 inches in size <br /> CK-': 1,?31 <br /> AC 0; '1425� <br />