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vas:nrF1.� County <br /> Industry Services Division Bumett <br /> \ <br /> 1'0$ '� . 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> P$ P.O. Box 7162 _"'r�/ <br /> ` Madison,WI 53707-7162 �r� ! <br /> 04 <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(1)(m),Stats. <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Timothy&Maya King 07-012-240-15-11-5 15-725-046000 <br /> Property Owner's Mailing Address Property Location <br /> 4124 Tall Moon Pass <br /> Govt.Lot <br /> City,State Zip Code Phone Number '/4, '/4, Section I 1 <br /> Danbury,WI 54830 (circle one) <br /> T40NI5; RWEorW <br /> H.Type of Building(check all that apply) Lot N <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms -3 34,35,36 Subdivision Name <br /> Tall Moon Add to Voyager Village <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number El Village of <br /> ® Town of Jackson <br /> III.Type of Permit: Check only one box on line A. Complete line B if applicable) <br /> A. ❑New System ❑ Replacement System ❑ TrcatmenUHolding Tank Replacement Only ❑ Other Modification to F,xisting 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 /> W.type of POWTS S stem/Com onentfDevice: (Check all that a t ) <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.Dis ersa[/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sl) System Elevation <br /> 450 Rate(gpdst) 642 646 96.5 <br /> .7 <br /> VI.Tank Info Capacity in <br /> c o <br /> Gallons Total #of Manufacturer <br /> Gallons Units v o 1 <br /> New Tanks Existing Tanks V in H il, <br /> Septic or Holding Tank x 1000 1 Huflcutt Z ❑ ❑ El ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) 1;;�� <br /> MP/MPRS Number Business Phone Number <br /> Luke Schmitz 884121 715-468-2434 <br /> Plumber's Address(Street City,State,Zip Code) <br /> PO Box 160 Shell Lake Wl 54871 <br /> VIII.County/Department Use Only <br /> bpApproved ❑ Disapproved Permit Feef'- 00Daattee Issued Issuing Agent Signature <br /> El Owner Given Reason for Denial $ 3 7J• 7'17' J— J <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> IRENE <br /> (r I Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x i es <br /> (21 <br /> 0 <br /> SBD-61398(1103/14)f)G/t BURNETT COUNTY <br /> ZONING <br />