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} s.ARTA4 T Industry Services Division County <br /> 4822 Madison Yards Way BURNETT <br /> i j` ' $p 0 rt Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 S-lk- --as — t 3 1 <br /> �� ` s''' Madison,WI 53707-7162 L th ,) t c--i--,_°1C- <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 5806 C.T.H. A <br /> purposes in accordance with the Privacy Law,s.I5.04(1)(m),Stats. <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> TODD RADNUZEL 14096 <br /> Property Owner's Mailing Address Property Location <br /> 107 S. LOCUST STREET Govt.Lot 6 <br /> City,State Zip Code Phone Number <br /> ROBERTS, WI 54023 715 - 781 - 4712 %, 1/4, Section 36 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 16 E or W <br /> Ell or 2 Family Dwelling—Number of Bedrooms 2 NA Subdivision Name <br /> Block# NA <br /> Uublic/Commercial—Describe Use <br /> NA ❑City of <br /> State Owned—Describe Use CSM Number ❑Village of <br /> NA ❑✓ 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 ew System ERe lacement System ['other Modification to ExistingSystem(explain) Additional Pretreatment Unit(explain) <br /> ❑N Y I✓ P Y ❑O Y ( P ) ❑ ( P ) <br /> B' Holding Tank Ian-Ground at-Grade ['Mound I❑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 DispersaVTreatment,Area,and,Tank Information: :; <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 2.0 150 195 97.20 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units "8 New Tanks Existing Tanks a c y 2 Ti <br /> n, c) in . rn ix, C7 a <br /> Septic or Holding Tank 1060 1060 1 INFILTRATOR I I r l ✓ <br /> _ n n, . <br /> Dosing Chamber 1060 60 1 INFILTRATOR u u ❑ ❑ ✓ <br /> V.Responsibility Statement-:,the"iutderslgned, ' e res'*. ility for installation of the POWTS shown on the attached'puns:t'''. <br /> Plumber's Name(Print) Plu e/s Si rh MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON .(1.-.- 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) 6 <br /> 9306 BLACK BROOK RD., WEBSTER, WI 54893 <br /> VI County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Is ng Age Signature <br /> /, 0 Owner Given Reason for Denial s 146 6f� 1! 42 <br /> Conditions of Approval/Reasons for Disap royal <br /> Mee-4- All 50( .t © C Q d C <br /> �► u(K ale-et15 ec;.Q --'''- '1 `� <br /> �elnc iM be V©o <br /> j � JUN 1 5 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not les than 8 1/2 x 11 iiib.KElRtVAc Unty <br /> Land Services Department <br /> SBD-6398(R.03/21) <br />