Laserfiche WebLink
R'kttiT� Industry Services Division County <br /> }� r 4822 Madison Yards Way BURNETT <br /> �e rt Madison,WI 53705 Sanitary Permit Number(toe filled in by Co.) <br /> " gp$' i P.O.Box 7162 �7 ���� I <br /> \��\ �#�Z t0C� CSI - <br /> Madison,WI 53707-7162 -DD <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 NA <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 SAME ll <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. / <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> BRETT H. & KELLY F. SCHULTZ 07-014-2-38-15-045 15-685-016000 <br /> Property Owner's Mailing Address Property Location <br /> 24754 SAND LAKE SHORES TRAIL Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> WEBSTER, WI 54893 651 - 248 - 1981 %. V., Section 04 <br /> 11.Type of Building(check all that apply) Lot# T 38 N R 15 E or W <br /> Fv�l I or 2 Family Dwelling-Number of Bedrooms 3 6 Subdivision Name <br /> Block# SAND LAKE SHORES <br /> ablic/Commercial-Describe Use <br /> NA ❑Cityof <br /> ❑State Owned-Describe Use CSM Number Ovillage of <br /> NA ID TO.of LAFOLLETTE <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. ❑Mew System Replacement System ❑Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B' [:]Holding Tank LLZIn-Ground at-Grade ❑Mound Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ❑Renewal Before ❑Revision ❑Change of Plumber ❑Transfer to New Owner tst Previous Permit Number and Date Issued <br /> Expiration SAN-21-150/08-25-17 <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 /> 450 0.7 642.86 652 94.40 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o g <br /> New Tanks Existing Tanks c d A <br /> w U ii y rn 1. v a <br /> Septic or Holding Tank 2500 2500 1 WIESER ✓ <br /> Dosing Chamber 750 750 1 WIESER F7711=11=1 1= B <br /> V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu is S ture MP1'MPRS Number Business Phone Number <br /> CORY J. JACKSON 8,' 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 BLACK BROOK RD., WEB TER, WI 54893 <br /> VI.County/Department Use Only <br /> 1?'A'pproved ❑Disapproved Permit Fee Date Issued Iss ing ent Sig <br /> ❑Owner Given Reason for Denial 7 6; <br /> Conditions of Approval/Reasons for Dis proval _ <br /> Ace f a g 5 e*Ac <br /> t�_4 JUN i 5 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1 x 11 in e <br /> AY ervices Department <br /> SBD-6398(R.03/21) <br />