Laserfiche WebLink
/ <br />/t3''rQa <br />t <br />o <br />Industry Services Division <br />1400 E Washington Ave <br />County <br />BURNETT <br />.t be filled in by Co.) <br />S <br />P$4 ON CO <br />PUTER/�7162 <br />Sanitary Number (to <br />r (P <br />a s 3707-7162 <br />I <br />� <br />i w4 <br />Sanitary Permit Application <br />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 />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. 15.0 1 m Stats. <br />L Application Information — Please Print All Information <br />Property Owner's Name <br />Parcel # <br />JOHN & DENISE PEAKE <br />07-024-2-39-14-22-2 02-000-011000 <br />TAX#16078 Pin#024312201500 <br />Property Owner's Mailing Address <br />Property Location <br />25978 COUNTY HIGHWAY H <br />Govt. Lot <br />NW !'s, NW iX4, Section 22 <br />City, State <br />Zip Code <br />Phone Number <br />SPOONER, WI <br />54801 <br />(circle one) <br />T39N R14WEorW <br />H. Type of Building (check all that apply) <br />Lot # <br />Subdivision Name <br />® 1 or 2 Family Dwelling — Number of Bedrooms <br />❑ Public/Commercial — Describe Use <br />Block # <br />❑ City of <br />❑ State Owned — Describe Use <br />[:1 Village of <br />CSM Number <br />40 ACRES <br />® Town of RUSK <br />IIL <br />Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />I ❑ New System <br />® Replacement System <br />❑ Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B <br />❑Permit Renewal <br />❑Permit Revision <br />❑Change of <br />❑Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />Owner <br />IV <br />Type of POWTS System/Component/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 />-4 <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />600 <br />Rate(gpdsf) <br />857 <br />900 <br />>=87.4'<=89.4' <br />.7 <br />VL Tank Info <br />Capacity in <br />Gallons <br />Total # of <br />Gallons Units Manufacturer <br />n o <br />U . m <br />c a <br />New Tanks Existing Tanks <br />U y 66 <br />Septic or Holding Tank320 <br />1000 <br />1320 existing Skaw 1000 new 320 <br />® ❑ ❑ ❑ ❑ <br />Dosing Chamber <br />❑ ❑ ❑ ❑ ❑ <br />VII. Responsibility Statement- 1, the undersigned, assume respo 'hility for inst ation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's Signature <br />MP/MPRS Number <br />Business Phone Number <br />Mel Ferguson dba <br />MPRS 224879 <br />Plumber's Address (Street, City, State, Zip Code) <br />VIII. Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />I ued <br />suing <br />i <br />❑ Owner Given Reason for Denial I <br />S <br />/Date <br />IX. Conditions of Approval/Reasons for Disapproval <br />run <br />0-5 hI <br />cc�c.� <br />Ljj <br />, ►v�����a�'`,�� <br />JUN -7 2017 <br />� �,`� <br />Xttach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inchesidURNETT COUNTY <br />ZONING, <br />