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Safety and Buildings Division County <br /> AA I201 W. Washington Ave., P.O. Box 7162 Burnett <br /> fiseonsin Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commerce (608)266-3151 49 <br /> /41� <br /> Sanitary Permit Application State Plan I.D.Number <br /> In accord with Comm 83.21,W is.Adm.Code,personal information you provide <br /> may be used for secondary purposes Privacy Law,sl5.04(l)(m) Project Address Cf different than mailing address) <br /> 1. Application Information-PI ease Print All Info 'on ( -4-JQ��j(P_, <br /> Property Owner's Name V Parcel N Lot p Block q <br /> Jeff& Ginger Whitman (fig- I-IIIb-b t-yob <br /> Property Owner's Mailing Address Property Location <br /> 29046 McKenzie Rd. SW A, NWA, Scene 12 Q <br /> City,State Zip Code Phone Number <br /> T40 N; R 14 ED or W® DO <br /> Spooner, WI 54801 715 635-8993 ulf <br /> 11.Type of Building(check all that apply) <br /> Subdivision Name CSM Number <br /> ® 1 or 2 Family Dwelling- Number of Bedrooms 3 <br /> ❑ Public/Commercial-Describe Use <br /> ❑City❑Village ®Township of SCOtt <br /> ❑State Owned- Describe Use <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 ❑ Other Modification to Existing System <br /> On <br /> B. ❑ Permit Renewal ❑ Permit Revision 0 Change of ❑Permit Transfer to List Previous Permit Number and Date Issued <br /> Before Expiration Plumber New Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> ® Non-Pressurized In-Ground ❑ Mound > 24 in.of suitable soil ❑ Mound < 24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter <br /> ❑Constructed Wetland ❑ Pressurized In-Ground ❑ 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: u-Quick 4 Infiltrators <br /> Design Flow(gpd) Design Soil Application Rate(gpdso Dispersal Area Required(s0 Dispersal Area Proposed(st) System Elevation <br /> 450 .7 643 649 94.0' <br /> V1.Tank Info Capacity inNumber Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons of Units Concrete Constructed Glass <br /> !.nkc <br /> T7L <br /> Septic or Holding Tank I Wieser Concrete X <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII. Responsibility Statement- I,the undersi ned,assume responsibility for installation of the POINTS shown on the attached plans. <br /> Plumber's Name(Print) MP/MPRS Number Business Phone Number <br /> Travis Butterfield PI er's Signam 652879 715 634-6080 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O. Box 13188 Hayward, WI 54843 <br /> VI .Count /Department Use Only <br /> Approved 11 Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issu'n ge Signatur Stamps) <br /> Surcharge Fee) �r0� <br /> ❑ Owner Given Reason for Denial ✓ �-��—� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper rot less than 8112 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />