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Department of Safety County <br /> & Professional Services, <br /> Sanitary Permit Number(to be filled in by Co.) <br /> Rg Industry Services Division 3A.N _-2Y--.2? <br /> 4"t <br /> e57- 24/— .2k L % '3 <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 n mail g address) <br /> the Department of Safety and Professional Services.Personal infonnation you provide may be used for secondary .3�"Z9 ,/U�/4de. 'Y` `2 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. � <br /> I.Application Information—Please Print All Information (�%jG�// � J l 4..t.D <br /> Prope Olwner' )lame /e;c2b1 <br /> Parcel#DT 032 .2.q/- IS •2y- 5 D5- <br /> ,� �Q�/l �yc Z/S- 3 Cot'021 ooc <br /> Property Owner's Mailing Address Property Location <br /> (/17 a l9/}'l. IL+F% Govt.Lot Z <br /> Cit ,State / Zip Code Phone Number <br /> K/^�� r)is � pg/( S L..7 %, �, /<, Section z� <br /> 1/4A7 �4� �/ <br /> II.Typeof Building apply) Lot# T <1/ N R /5- E of <br /> (check all that PP Y) <br /> ❑ I or 2 Family Dwelling—Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> J2/ZZ ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑Village of <br /> 1//4)c 5Z -8'fownof cU,SS <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.)�le <br /> A. ICI New System ❑ Replacement SystemExisting System(explain) (explain) <br /> ❑ Other Modification to ex lain) ❑ Additional Pretreatment Unit <br /> B. <br /> ❑ Holding Tank ❑ In-Ground ❑ At-Grade ❑ Mound Li Individual Site Design Li Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> ❑ Transfer to New Owner <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 Elevatipn <br /> . 7 rt ?7-6 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units u o -° <br /> ro <br /> New Tanks Existing Tanks � T �y c"a_ rs <br /> a <br /> 0 2 <br /> U 7 v c C7 P. <br /> Septic or Holding Tank Mq-> / (+/'1�( <br /> Dosing Chamber / " <br /> V.Responsibility Statement- I,the undersigned,assume responsibil' r installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si ture MP/MPRS Number Business Phone Number <br /> Cory Jackson 82339 715-791-4768 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 24884 State Rd 35, Siren WI 54872 <br /> VI.County/Department Use Only <br /> { Approved ❑Disapproved Permit Fee Date Issued Issuing'`�ui'� Agent� Signature <br /> ❑Owner Given Reason for Denial $ ILi��7fl 3(�1 ZoZ `1�� WVC ¢---j�L i4'l <br /> Conditions of Approval/Reasons for Disapproval <br /> llTPe+ aL l St✓+toA..s• <br /> EIVE <br /> .gyp ll DW au Ccx��`f au) S- t,-le ret u irer�rc¢1' ' �S' <br /> -rip, 4 ,fi1-fi -o h <br /> r u�d e ele,-ftra.iVd d,4 <br /> �e ,ri�., 0 nS p-ec " � 1 MAR a a 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 inches in sizt5urnett bounty <br /> Land Services Department V, J <br /> SBD-6398(R.03/22) $ J25- rA Wk 4 5(t' <br />