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drrdrypgT County <br /> Industry Services Division BURNETT <br /> M 1400 E Washington Ave <br /> Sanitary Permit Number(to be filled in by Co.) <br /> p '� P.O. Box 7162 pp /� <br /> Madison,WI 53707-7162 _DO7&6 <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 /> purposes in accordance with the Privacy Law,s. 15.04 l m,Stats. PARDUN RD. <br /> I. Application Information-Please Print All Information 089001, <br /> Property Owner's Name Parcel# <br /> JEROME&BONNIE WILSON 07-036-2-40-17-14-3 02-OW-011000 <br /> Property Owner's Mailing Address Property Location <br /> 24792 VIOLA LAKE RD <br /> Govt.Lot <br /> City,State Zip Code Phone Number NWE'/4,SW 1/4, Section 14 <br /> WEBSTER,WI 54893 (715)791-0300 (circle one) <br /> T40N; R17WEorW <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms r� Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> ® Town of UNION <br /> III.T e 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 S stem/Com onent(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.Dispersairfreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sfl Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdst) 642.86 642.86 91.0' <br /> .7 <br /> VI.Tank Info Capacity in <br /> G 7 V <br /> Gallons GaTotal llonsUn ts Manufacturer 1 <br /> New Tanks Existing Tanks U rn y ia. 0 0. <br /> Septic or Holding Tank 1000 1000 1 WIESER CONCRETE ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber I I ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersign d,Vssume r sibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P tuber's Sign MP/MPRS Number Business Phone Number <br /> CORY JACKSON 824339 715-566-2786 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 BLACK BROOK RD. WEBSTER,WI 54893 <br /> VIII.Coun /De artment Use Only <br /> [k Approved ❑ Disapproved P // <br /> ermit Fees, Date Issued Issuing Agent Signature <br /> ,\ <br /> El Owner Given Reason for Den ial $ �'5 ' t.P — LZ <br /> UL Conditions of Approval/Reasons for Disapproval D E fn1 <br /> JUN <br /> IN 12LLrr���5 2�L011/51L5� <br /> on <br /> C°s1 1�� Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1I incJWs in size <br /> URNETT COUNTY <br /> SBD-6398(803/14) <br /> ZONING <br />