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rrar"'4� Department of Safety c°°nty <br /> BURNETT <br /> & Professional Services, <br /> Sanitary Permit Number(to be filled in by Co.) <br /> Industry Services Division s pj,a4t — 3 _ <br /> K- <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 than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary 142 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Slats. ASPEN HILL TRAILWAY <br /> I.Application Information—Please Print All Information <br /> Property Owner's Name Parcel# -rax IV (,e395 <br /> VOYAGER VILLAGE POA (BUYER: DHI HOLDINGS LLC) 7-012-2-40-15-22-5)95-030-085000 <br /> Property Owner's Mailing Address Property Location <br /> 28851 KILKARE ROAD Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> DANBURY, WI 54830 14, '/., Section 22 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 15 Y W <br /> CYJ or 2 Family Dwelling-Number of Bedrooms 3 75 Subdivision Name <br /> Block# VOYAGER VILLAGE <br /> ❑Public/Commercial-Describe Use <br /> NA ❑city of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA Ckown of JACKSON <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. <br /> -.flew System Replacement System Other Modification to Existing System(explain) 11 Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank X in ground ❑ At-Grade Individual Site Design Other Type(explain) <br /> (conventional) add filter <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑Transfer to New Owner ist Previous Permit Number and Date Issued <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 Elevation <br /> 450 0.7 C (L13 1 650 98.86 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units <br /> New Tanks Existing Tanks v c 0 p <br /> a U an y rn V. U P, <br /> Septic or Holding Tank 1000 1000 1 WIESER (COMBO) X <br /> Dosing Chamber 650 650 X <br /> V.Responsibility Statement—I,the undersigned,assume res nsibi for stallation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Si $, reY MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 24884 S.T.H. 35, SIREN, WI 54872 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee (Date Issued <br /> �7 Issuing Agent Signature <br /> ❑Owner Given Reason for Denial $ (L V I O 2V y <br /> Conditions of Approval/Reasons for Disapproval <br /> mkt am �ckba�,k S -45 7-7 t L <br /> aci cmn4-1 and s4a-k (efuil'e,e-iS E(0` E �V F <br /> MAR 2 b 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 11 inckep4la urneft County <br /> Land Services Department <br /> SBD-6398(R.03/22) <br />