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UN /'.e V, Safety a id Buildings Division County <br /> 201 W.Wash ngton Ave.,P.O.Box 7162 Bumea <br /> Madis ll WI 53707-7162 Sanitary Pei mit Number(to be filled in by Co.) <br /> 499,45 <br /> Sanitary Permit Application State Tramu ction Numb <br /> In accordance with s.Comm.83.21(2),Wis.Adm.Code,sub mission of this I 3im to the appropriate governmental <br /> unit is required prior to obtaining a sanitary permit. Noe: Application orms for state-owned POWTS are <br /> submitted to the Department of Commerce. Personal in tion you vide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m) Stats. 27268 CO H Spooner \ <br /> I. Application Information-Please Print All Infor nation <br /> Property Owner's Name Parcel# <br /> Bob Matalik Ice Matalik estate �/-�-a 028 4133 02 300 <br /> Property Owner's Mailing Address TT Property Lc union ,,rr <br /> N12010 Pash RD Govt.Lot 2 14-4, 5 125 of Co IlwY R <br /> City,State state Phone Number % '''A, Section_33 <br /> TREGO W1 715 466-5252 — <br /> S - q/5bT (circle one) <br /> II.Type of Building(check all that apply) Lot# —40N; R 14 W— <br /> Xl or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use ❑ City of <br /> ❑State Owned-Describe UseCSM Number ElVillage f <br /> X Town of <br /> SCOTT <br /> BL Type of Permit: (Check only one box on line k Complete lit e B if applicable) <br /> A. ❑New System XReplacement System Treatment/Ho ding Tank Replacement Only ❑Other M 'lication to Existm8S stem(explain) <br /> B. 11 Permit Renewal ❑ Permit Revision Change of PI bar 11 Permit Transfer to New <br /> List Previou i Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POINTS S stem/Com onent/Device: heck all thatapply) <br /> X 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(expla ) <br /> V.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal is va Required(sf) Dispersal Area Proposed(E D I System Elevation <br /> 300 .7 428 428 <br /> 9✓-W 60 <br /> VI.Tank Info Capacity in To #of Manufacturer <br /> Gallons Gall is Units <br /> New Tanks Existing Ten o v A s m <br /> COMBO U y „ h <br /> Septic or Holding Tank X O 10 O 1 Huffeutt X <br /> Dosing Chamber X O 62 1 HUM= X <br /> VII.Responsibility Statement- I,the undersigned,assume risipariallill'ty for installation of the POWTS shown on the bed plans. <br /> Plumber's Name(Print) Plum s S tore MP/MPRS Numl er Business Phone Number <br /> Ken Schmitz MPRS 224173 (715)468-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 160 Shell Lake,WI 54871 <br /> VIII.Coun /De artment Use 0 77 <br /> 0 Approved ❑Disapproved P 't Fee Date Issued Issuing <br /> $ Signa ire <br /> C,, a <br /> ❑Owner Given Reason for Denial 250 1I PRI L, 07 <br /> IX Conditions of Approval/Reasons for Disapprov4I <br /> AIoTE. 4mocsi Cett 504-" XaANA-rl 15 AT liwiir l,aAtT <br /> Attach to complete plans for the and aubmi to the County only on paper not less than 8 vt r 11 inct m in size <br /> SBD-6398(K 01/07)Valid thru 01/09 <br />