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`1 GOMPUTEWSCANNED <br /> commerce.wl.gov Safety and Buildings Division Coun <br /> 201 W. Washington Ave.,P.O.Box 7162 Burnett <br /> (lc scotnsin Madison,WI 53707-7162 Sanitary Pe it Number(to be filled in by Co.) <br /> epartnamt of Calm arce 49(R55Z <br /> Sanitary Permit Application State forms ction Number <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Note: Application fortes for state-owned POWTS are Project Add ass(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary Spangb¢ g Rd. <br /> putposes in accordance with the Privacy Law,s. 15.04 l (m),Stars. ((�� <br /> I. Application Information-Please Print All Information J— <br /> Property Owner's Name Parcel# <br /> Timothy and Lynn O'Connell 006-241 01 700 <br /> Property Owner's Mailing Address Property Lo mtion <br /> 3043 Zia St.NE <br /> Govt.Lot <br /> City,State Zip Code Phone Number NWI/4- 1/4 Section 10 <br /> Rio Rancho NM 87144 505-896-6934 (circle one) <br /> T38N; R17Eo�W <br /> H.Type of Building(check all that apply) Lot# <br /> 1 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village f <br /> Town of Daniels <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A' New System ❑ Replacement System y p y ❑ TreatmenUHolding Tank Replacement Only ❑Other M ification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber102,71a <br /> Transfer to New List Previou Permit Number and Date Issued <br /> Before Expiration <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(expl ) <br /> V.Dis ersaOTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Ra[e(gpdst) Dispersal Area Required(st) Dispersal Area Proposed( System Elevation <br /> 300 .6 500.00 520 sq.r.Based on Eisa t Cell#1 =90.40' <br /> 20.0 x 26 Chambers Cell#2=89.90' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o d g <br /> New Tanks Existing Tanks <br /> aU ti y Z 'w0 a, <br /> Septic or Holding Tank 750 750 1 Wieser Concrete X <br /> Dosing Chamber <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibil!94or installation of the POWTS shown on the a flached plans. <br /> Plumber's Name(Print) Pl r Sign a MP/MPRS Num r Business Phone Number <br /> Robert Carlson 135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Cade) <br /> 3572115th Street Frederic WI 54837 <br /> V,ill.County/Department Use Only <br /> LJ Approved ❑ Disapproved Permit Fee Date Issued Issuing A ature <br /> $ <br /> ❑ Owner Given Reason for Denial p� /4i1_44 07 <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not Iess than 8 in x 11 inc es in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />