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County <br /> Industry Services Division Burnett <br /> 1400 E Washington Ave <br /> 3 $P P.O.BOX 7162 Sari /�Pe�rmL Permit N/umber(to be filled in by Co.) <br /> or� Madison,WI 53707-7162 %-TTJ�-3 <br /> `"`raslbenL <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 G p u niT'f /�jP 1/r`�f/ <br /> is required prior to obtaining a sanitary permit. Note:Application forts for state-owned POWTS are submittedto �. Address of different than mail' <br /> the Deparnnent of Safety and Professional Services. Personal information you provide may be used for secondary J (i ung address) <br /> purposes in accordance with the Privacy Law,s. 15.04(l m,Stals. 22622 Johnson Rd. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Stephen and Jodi Schlader 07-014-2-38-15-35-5 05.006-016000 <br /> Property Owner's Mailing Address Property Location <br /> 2719 E.Silverwood Dr. <br /> Govt.Lot 6 <br /> City,State Zip Code Phone Number /4, %4, Section 35 <br /> Phoenix,AZ 85048 480-221-7263 (circle one) <br /> T39N R15EorW <br /> H.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name <br /> NA <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> 1365 Vol.7 Pg.23 ®Town of LaFollene <br /> III.T of Permit: Check only one box on line A Complete line B if applicable) <br /> A. ❑Now System ❑Replacement System ® Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Chau of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner i( 7z �Zr+r yI <br /> t/7 <br /> IV.Type of POWTS S stem/Com nent(Device: Check all thatapply) <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) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(st) System Elevation <br /> 450 Rate(gpdst) Existing 630 sq.ft. Na Existing <br /> Na <br /> VL Tank Info City in <br /> Gallons Total # it Manufacturer w 0 U 13 <br /> Gallons Unity <br /> New Tanks Existing Tanks s a V (AB ti w C7 w <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete 0 El 11 0 ❑ <br /> Dosing Chamber ❑ ❑ <br /> VII.Responsibility Statement-1,the umdersiga amu responsibility for injallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim) PM, MP/MPRS Number Business Phone Number <br /> Dayton Daniels �� 007086 715-349-5533 <br /> �z I <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 326 Siren WI 54872 <br /> II.CountyADepartment Use Only <br /> Approved ❑ Disapproved Permit Fee 97� Date Issued Issuing Agent Signature <br /> ❑ Owner Given Reason for Denial $,lm7s' <br /> IX Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system ab submit to the County only on paper not less than 8 t!t 111 ioches in sin <br />