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*"Rt" r Department of Safety County <br /> T BURNETT <br /> & Professional Services, <br /> Sam Permit Number(to be filled in by Co.) <br /> Industry Services Division 5AN—2 4- 29d- <br /> try 2 - 4o60213 7 <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 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. <br /> I.Application Information-Please Print All Information 20460 C.T.H. Z (SAME) <br /> Property Owner's Name Parcel# <br /> ALLEN ROSS &JUNE ANNE LARSON TAX ID: 35390 <br /> Property Owner's Mailing Addres Property Location <br /> 20460 C.T.H.Z Govt.Lot 8 <br /> City,State Zip Code Phone Number <br /> LUCK, WI 54853 715-553-2198 i<. v<, Section 27 <br /> II.Type of Building(check all that apply) Lot# T N R 18 <br /> IN or 2 Family Dwelling-Number of Bedrooms 3 NA Subdivision Name <br /> Block# NA <br /> ❑Public/Commercial-Describe Use <br /> NA ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA Ekownof TRADE LAKE _ <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 /> `4' New System X Replacement System Other Modification to Existing System(explain) (explain) <br /> ❑ Additional Pretreatment Unit <br /> B' ❑ Holding Tank X in ground ❑ At-Grade A&W Individual Site Design Other Type(explain) <br /> (conventional) add filter <br /> C. El Renewal Before ❑ Revision El Change of Plumber ❑ Transfer to New Owner <br /> ist Previous Permit Number and Date Issued <br /> Expiration 378930/10-11-2000 2y555 10111 L00 <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(so <br /> System Elevation <br /> 450 0.5 900 900 191.50; 91.00; 90.00 FT. <br /> Capacity in Total #of Manufacturer 0 <br /> Tank Information Gallons Gallons Units 1, c T 2 <br /> New Tanks Existing Tanks a v <br /> 0 <br /> a U in h yr w C7 CL <br /> Septic or Holding Tank I coo 1000 1 MCKENZIE CONCRETE X <br /> Dosing Chamber <br /> V.Responsibility Statement- 1,the undersigned,assume respo ibili or in Nation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Sign MP/MPRS Number siness Phone Number <br /> Bu <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 IssQued 7 Issuing Agent Signature <br /> ❑Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <br /> Dro EP V E <br /> � <br /> g�S-k4" -10 � �Ira n�d rli' l NOV 13 2024 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1rnQ2�E <br /> ent <br /> SBD-6398(R.03/22) <br />