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fou"rr'�r county <br /> Industry Services Division BURNETT <br /> 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.)P.O. Box / � / 1 q <br /> Madison,WI 53770707—7162 (OV ID "I <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)(mStats. E.YELLOW RIVER RD AND WHITETAIL TRAIL <br /> L Aplification Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> JORDAN CHRISTOPHERSON 07-020-2-40-16-07-5 15-580-072000 <br /> TAX#14294 <br /> Property Owner's Mailing Address Property Location <br /> 26400 INDIAN MOUNDS RD <br /> Govt.Lot 3 S 200'Nl/2 <br /> City,State Zip Code Phone Number '/y !4, Section 07 <br /> NORTH PRAIRIE,WI 53153 262 470 3903 (circle one) <br /> T40N R16WEorW <br /> II.Type of Building(check all that apply) Lm# <br /> ® I or 2 Family Dwelling-Number of Bedrooms 62+1/62 INT IN OUT LOTS Subdivision Name <br /> 1,2&3 n / <br /> ❑Public/Commercial-Describe Use f'aI[tvIvrkler weir <br /> Block# <br /> ❑State Owned-Describe Use Cl City of <br /> CSM Number ❑ Village of <br /> 2.23 ACRES ® Town of OAKLAND <br /> )a a of Permit: (Check only one box on tine A. Complete tine 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 tn/Com nent/13mce: (Check all that apply) <br /> ® Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 irL of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dis rsal/Tteatmtmt Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(si) Dispersal Area Proposed(sf) System Elevation <br /> 300 Rate(gpdsf) 432 450 »1.9'<--92.4' <br /> .7 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of Gallons Units <br /> Manufacturer New <br /> o U <br /> New Tanks Existing Tanks U m m 9 C7 <br /> Septic or Holding Tank 700/300 1000 SKAW CHAMBERED ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ 0 ❑ <br /> VII.Responsibility Statement- 4 the undersigned,assume respondbttky for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI iplaWre MP/MPRs Number Business Phone Number <br /> Mel Ferguson dba c P ✓ MPRS 224879 ^ <br /> Plumber's Address(Street,City,State,Zip Code) <br /> Cowl�u lira <br /> �VDI <br /> Conn /De art nt Use 0ab, <br /> Py Approved ❑ Disapproved Permit Fee�D pDate Issued Issues Agent Si <br /> ❑ Owner Given Reason for Denial $ -3 7 <br /> DL Conditions of ApprovaMeasons for Disapproval R.4'. ECEI E <br /> SEP 18 2017 <br /> Attach to complete plans for the tyslem and submit totheCountyonlyon papernot loss thona l/t z ll siu <br /> BURNETT COUNTY <br /> ZONING <br />