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County <br /> 1 industry Services Division BURNETT <br /> S 1400 E Washington Ave <br /> P P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,Wl 53707-7162 �f�►v`23 —13 �tz/�(off(o <br /> � ALg� - 3 -O <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 <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if different than mailing address) <br /> vurooses in accordance with the Privacy Law,s.15.04 1 m Stats. 3880 CTH B <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> COREY&SAMATHA DAVIS <br /> Property Owner's Mailing Address Property Location <br /> 3880 CO.RD.B <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE'/4,SE'/a, Section 23 <br /> SHELL LAKE,WI 54871 rcle one) <br /> T38N R15EotW <br /> II.Type of Building(check all that apply) 14 <br /> Lot# <br /> ® 1 or 2 Family Dwelling—Number of Bedrooms _ 1 Subdivision Name <br /> ❑Public/Commercial—Describe Use Block# <br /> ❑ City of <br /> ❑ State Owned—Describe Use CSM Number ❑ Village of <br /> ® Town of LA FOLLETTE <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 Only ❑ Other Modification to Existing System(explain) <br /> B ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> ®Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 600 Rate(gpdsf) 857 858 93.66&90.66 <br /> .7 <br /> VI.Tank Info Capacity in o <br /> Gallons <br /> Total #of Manufacturer <br /> Gallons Units c .. ? <br /> New Tanks Existing Tanks c� U va v vs w C7 0. <br /> Septic or Holding Tank 1 1250 1250 1 SKAW ® ❑ ❑ <br /> Dosing Chamber ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum Si a re ! MP/MPRS Number Business Phone Number <br /> ROBERT HARDINA 4 u r 824825 715-491-5039 <br /> Plumber's Address(Street,City,State,Zip Code) t <br /> 477 170TH AVE TURTLE LAKE WI 54889 <br /> VIII.County/De artment Use Only <br /> Er Approved [I Disapproved Permit Fee Date�s�s�ued sing �e S: ature a D <br /> ❑ Owner Given Reason for Denial $ („�V c6 I/-1104k' tD <br /> IX.Conditions of Approval/Reaso s for Disapproval u b. a` ;,�cf�$ 4a have O'7� y c� <br /> B SkS SL -b a6 t nc�� 1 skM e 44.5t <br /> sal- n. 00 <br /> q r/B/1IGL rag <br /> yqu.� 0gas� �b cf -!v ex�-s�' 4n� <br /> 19-ti 5�g, ntwS e /� <br /> Attach to complete plans for the stem and submit fo the County only on paper not less than 8 112 x 11 inches in size <br /> Cko CJL 3 o <br /> SBD-6398(R03/14) 's g2500 <br />