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Yiyrs_ii Industry Services Division County <br /> j 4822 Madison Yards Way Burnett <br /> aj`\ II$r N <br /> _' Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> ? ' P.O.Box 7302 <br /> `— Madison,WI 53707 j f.31,—.22—Lig (eM 3437 <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 7142 S DEVILS LAKE DR <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> BRIAN B & BRENDA M FREY LIVING TRUST 07-020-2-40-16-33-5 05-004-015000 <br /> Property Owner's Mailing Address Property Location <br /> 1589 EVAN CT Govt.Lot 4 <br /> City,State Zip Code Phone Number <br /> NEW RICHMOND WI 54017 651-485-2934 %, 1/4, Section 33 <br /> IL Type of Building(check all that apply) Lot# T40 N R 16 E o6) <br /> Ell or 2 Family Dwelling—Number of Bedrooms 2 2 Subdivision Name vvv <br /> Block# <br /> Dublic/Commercial—Describe Use <br /> EICity of <br /> u ❑ <br /> State Owned—Describe Use CSM Number Village of <br /> Town of Oakland <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. Clew System CReplacement System EIther Modification to Existing System(explain) DAdditional Pretreatment Unit(explain) <br /> B. Holding Tank ❑In-Ground Et-Grade ['Mound ❑Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑Renewal Before ❑Revision ❑Change of Plumber Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/st) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units 0 'g tizi <br /> New Tanks Existing Tanks g c 2B Y 3 ro <br /> a.O in o, to X C7 a, <br /> Septic or Holding Tank X 3000 1 Wieser f ✓ IF-II U L <br /> Dosing Chamber <br /> uua n V.Responsibility Statement-I,the undersigned,assume r onsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) umb ' atur MP/MPRS Number Business Phone Number <br /> Luke Schmitz i------- 884121 715-520-2434 <br /> Plumber's Address(Street,City,State,Zip Code C------ ' <br /> PO Box 160 Shell Lake WI 54871 <br /> VI.County/Department Use Only <br /> Permit Fee O Date Issue n Is AgetSiEna. <br /> rApproved ❑Disapproved $. '❑Owner Given Reason for Denial ? -�/ r / <br /> Conditions of Approval/Reasons for isapproval I/ _ <br /> ©Ace* all c-145 V L5; <br /> D <br /> APR 19 2022 j <br /> attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 a 11 inches in sizeBumett Cou <br /> _ Land Services Department <br /> �o <br /> SBD-6398(R.02/22) c1�� 3`� a 4. a 16 -- <br />