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Industry Services Division County <br /> 4822 Madison Yards Way Burnett <br /> 8s - Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> Ps P.O.Box 7302 A' 2 �'1 1�g <br /> Madison,WI 53707 '`t sa+� q I <br /> Sanitary Permit Application State Transaction Number 4�" <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 24837 Walber Road <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. 9 <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> DWAYNE & SHELLIE JACOBS 07-018-2-39-16-35-4 04-000-018000 <br /> Property Owner's Mailing Address Property Location IF 0 5 V <br /> 450 WHITE PINE LN Govt.Lot <br /> City,State Zip Code Phone Number <br /> SOMERSET WI 54025 715-338-2933 Se /,SE /, section 35 <br /> H.Type of Building(check all that apply) Lot# T39 N R 16 E or W <br /> D1 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> :Public/Commercial-Describe Use <br /> City of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> Town of Meenon <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. <br /> ✓iNew System Replacement System DOther Modification to Existing System(explain) DAdditional Pretreatment Unit(explain) <br /> B. Holding Tank ❑In-Ground LZ 't-Grade Mound ❑Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑Renewal Before Revision EiChange of Plumber Dfransfer 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/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 .5 600 600 98 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units v o '0 u <br /> U u m <br /> New Tanks Existing Tanks ,1 2 y Y -c a <br /> aU in . cr ii. 0 a <br /> Septic or Holding Tank x 840 1 Wieser 1 ✓ <br /> I L I <br /> Dosing Chamber x 500 1 Wieser I ✓ [J I _ <br /> V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI ber's . lure MP/MPRS Number Business Phone Number <br /> Luke Schmitz i./ 884121 715-520-2434 <br /> Plumber's Address(Street,City,State,Zip Cod <br /> PO Box 160 Shell Lake WI 54871 <br /> �Vr�ttI.County/Department Use Only <br /> /uJ Approved ❑Disapproved Permit Fee <br /> j Date Issued Issur A nt Sign. 4 re <br /> ❑Owner Given Reason for Denial $3 7./ 7( /?? C���, ./ <br /> Conditions of Approval/Reasons for Disapproval l <br /> 1f ee.A- al( 5 kbc C <br /> W -3y 3s <br /> 9D <br /> CC� GPIMGT <br /> 2 g Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11\i I hes size JUL 2 2 2022 _ <br /> SBD-6398(R.02/22) ""`"durnett County <br /> Lend 8ervioee Department AVIS <br />