Laserfiche WebLink
Generated by PDFKit.NET Evaluation <br /> County <br /> Oprn"WrOl wl,gov SafetyamlBuildingsDivision BURNETT <br /> 201 W.Washington Ave.,P.O.Box 7162 <br /> IiscOCommence Madison,W153707-7162 andaryPetmuN er(to be le m yCo.) <br /> tof <br /> 2 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.53.21(2),W is.Adm.Code,submission of this fort to the appropriate -Tr- <br /> governmental unit is requited prior to obtaining a sanitary permit. Nae:Application forms for sure-awned Project Address(i7diffitreat than mailing address) <br /> POWTS are submitted in the Department of Commerce. Personal information you provide may be used for (� <br /> secondary Purooses in accordance with the Privacy Law,s. 15. 1 m,Stan. 30456towerrdJV <br /> I. Application Information-Please Print AN information Parcel# <br /> Property Ownees Name 032 532401900 <br /> Shlrly tys :On # 3a`f�iProperty Location <br /> Property Owners Mading Address <br /> Govt <br /> 30456 tower rd /s, '/4, section 24 <br /> city, p o e one Num o (circle one) <br /> E orW <br /> danbury WI 54830 (715)656-3336 T 41 N; R 6 (' (� <br /> H.Type of Building(check all that apply) Lot# Subdivision Nam <br /> (e I or 2 Family Dwelling-Number of Bedrooms 2 Block# <br /> Public/Commercial-Describe Use (' Coy <br /> (� State Owned-Describe Use CSM Number (' village swiss <br /> (i Township o <br /> 111.Type of Permit: (Check only one box on Hue A. Complete line B if applicable) <br /> ('New System (:Replacement System ('Treatment/Holding Tank Replacement Only Other Modificigion to Existing System <br /> B. F- Permit Renewal r Permit Revision F—Change of F- Permit Transferm New List Previous PermitNumberand Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System: (Check all that apply) <br /> F Non-Pressurized In-Ground r prcssurixed ln-Crmund r Atlimde r Mound>24 in.of suitable soil <br /> Mound<24 in.of suitable soil <br /> F-Holding Tank r Other Disposal Component(explain) r Pretreatment Device(explain) <br /> V.Dispersal/Trestmeot Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) SysternFlevation <br /> 300.00 0.70 428.57 439.30 B9.70 <br /> VI.Tank Info Capacity in Total Number Manufacturer c <br /> Gallons Gallons of Units & 9 -8 <br /> ew xtstmg R .x 3 <br /> Tanis Tacks a U w <br /> Septieor Bolding Talc 800 800 1 Skew Pre-Cast G' r r r <br /> owing Clamber r r r f F <br /> VII.Responsibility Statement- L the undersigned,mums responsibility for installation of the POWTS shows on the nth ched plum. <br /> Plumber's Name(Print) PI s Siggrture MP/MPRS Number Bus him Phone Number <br /> Ross Tollander 851954 (715)866-8070 <br /> umbe s Address tteeq City,State,Zip Code) <br /> 27220 Jamison rd,Webster,WI 54893 <br /> VIIL Comity/Deportment Use Only <br /> Approved ('Disapproved Sanitary Permit I=(includes Groundwater Date Issued Win g ignature(No p9) <br /> Surcharge Fee) q� <br /> ❑OwnerGiven as <br /> Reon for Denial I <br /> IX.Conditions of Approval/Ressons for Disapproval n <br /> AUG 92007)IRN <br /> ETT C"4 <br /> Asach complete phms(to the County only)for the system on paper not km than 8112 sit inches in cue Z0 <br /> Click fta-W9 IlbC VV)IU4litNFa01/09 <br />