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Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> F <br /> Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) p <br /> isconsin (608)266-3151 N <br /> Department of Commerce <br /> State Plan I.D.Number <br /> Sanitary Permit Application 4&5 /S <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,s15.04(Ixm) Project Address(if different than mailing address) <br /> L Application Information-Please Print All Information ^ O Hwy 35 <br /> o� <br /> Property Owner's Name Parcel# Lot# BlockMazy # <br /> McCory&Jack Holmes 0a'r 53 —da._ <br /> Property Owner's Mailing Address Property Location <br /> P.O. Box 93 NW tG SEv., Section 12 <br /> City,State Zip Code Mone Number <br /> Danbury,W1 54830 T 41 N; R 16 E❑or W <br /> 17.Type of Building(check all that apply) <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑ State Owned-Describe Use_ ❑City❑Village ®Township of SWISS <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System Replacement System Treatment/Holding Tank Replacement Only ❑ other Modification to Existing System <br /> Permit Renewal ❑ Permit Revision Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> B' Plumber Owner <br /> Before Expiration <br /> IV. a ofPOWTS System: Check all that apply) <br /> ® Non-Pressurized In-Ground ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At Grade E] Single Pass Sand Filter <br /> ❑Constructed Wetland ❑ Pressurized In[Iround ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter <br /> ❑Recirculating Synthetic Media Filter ®Leaching Chamber ❑Drip Line ❑Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: 14-It-adadnd aiaIaaaa+ <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 .7 429 435 96.0' <br /> VL Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 750 - 750 1 Wieser Concrete x <br /> Aerobic Treatment Unit <br /> IMsing Chamber <br /> VII Responsibility Statement-1,the er igned, or Installation of the POWTS shown on the attached plow. <br /> Plumber's Name(Pritd) bar's Si MP/MPRs Number <br /> Business Phone Number <br /> Travis Butterfield 652879 715 634-6080 <br /> Plumber's Address(Street,City,S ip Code) <br /> P.O.Box 13188 Hayward,W154843 <br /> =Counrtment Use OnlSanitary Permit Fee(inclludes Groundwater Date Issued Issuing e t o Stamps) <br /> Disapproved Surcharge Fee)Owner Given Reason for Denial <br /> DL Conditions of Approval/Reasons for Disapproval <br /> Attach complete plum(to the County only)for the system on paper not lea than 81/2 111 inches in size <br /> SBD-6398 (R. 01/03) <br />