Laserfiche WebLink
arxr County <br /> °^ 'ndustry Services Division Bumett <br /> 1400 E Washington Ave <br /> + Sanitary Permit Number(to be filled in by Co.) <br /> P.O. Box 7162 ��, ` <br /> Madison,WI 53707-7162 �v-X-31 <br /> ��ta�ioray:,• <br /> Sanitary Permit Application State Transaction Numb <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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. County Line Rd. <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Coyland Creek LLC 07-014-2-28-15-31-4 04-000-011100 <br /> 33L-tl <br /> Property Owner's Mailing Address Property Location <br /> 5400 Town Line Rd. <br /> Govt.Lot <br /> City,State Zip Code Phone Number NW'/4,SE'/4, Section 4 <br /> Frederic,WI 54837 715-222-5000 cle one <br /> T38N R15Eor <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms Na Subdivision Name <br /> Na <br /> ❑Public/Commercial-Describe Use Block# <br /> Na El city of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> Na ® Town of LaFollette <br /> III.Type of Permit: (Check only one box on line A. Complete line B if a licable) <br /> A. ® New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner —� <br /> IV. Type of POWTS System/Component/Device: (Check all that apply) <br /> ® Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ®Other Dispersal Component(explain) Lift ❑Pretreatment Device(explain) <br /> V.Dis persal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 150 Rate(gpdsl) 300 390 104.50' <br /> .5 <br /> VI.Tank Info Capacity in <br /> c � <br /> Gallons Total #of Manufacturer U <br /> Gallons Units o ; Y New Tanks Existing Tanks n. U v� V cz w C7 G. <br /> Septic or Holding Tank 840 840 1 Wieser Concrete ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber 500 500 Combination ® 1 ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume resppnsiVity for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu r' i MP/MPRS Numbe7�7154653-2500 <br /> usiness Phone Number <br /> Robert Carlson 135655 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572 115`h St.Frederic WI 54837 i <br /> VIII.County/Department Use Only <br /> Approved ❑ Disapproved TPenmit Fee ' Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial �'r �' L ' z Ali, / (0 E tO � <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> rn <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inc in <br /> SBD-6398(R03/14) <br /> Umett County <br /> Land Services Department <br />