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• pfr`aTyr county <br /> j Industry Services Division BURNETT <br /> 1400 E Washington Ave <br /> P.O. Box 7162 Sanitary PermritlNumber(to be filled in by Co J <br /> 7\ _ Madison,WI 53707-7162 �� /5 <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(l m,Stats. N518//0 pSa Street _ // <br /> L Application Information-PleasePrintAllInformation �lpd�q �, �e�/1/Pi7 lk <br /> Property Owner's Name Parcel# <br /> DAV ID&TANIA GRAY <br /> 07-024-2-39-14-03-5 05--002-022000 <br /> Property Owner's Mailing Address Property Location <br /> 439 PARKVIEW LANE <br /> Govt.Lot 2 <br /> City,State Zip Code Phone Number Y., '/y Section 03 <br /> RIVER FALLS,WI 54022 (cu' one) <br /> T39N RJ44IE ofW <br /> IL Type of Building(check all that apply) Lot# <br /> �1 <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms ! 1 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑ State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> .49 ACRES#617 V3 P48 ® Town of RUSK <br /> III T e of Permit: Check only one box on line A Complete line 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 System/Component/Device: (Check all that apply) <br /> ® Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ AI-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> ❑ Holding Tank ❑Other Dispersal Component(explain) ❑Prctreatrnmt Device(explain) <br /> V.Dis rsal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application DispersalArea Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 Rate(gpdsf) 432 450 89.0'TO93.5'MULTI-LEVEL <br /> .7 <br /> VL Tank Info Capacity in <br /> v G O U <br /> Gallons Total #of 14fanufacturer o U 2 " .9 <br /> Gallons Units m p ry o w a <br /> New Tanks Existing Tanks r, , <br /> Septic or Holding Tank 700-300 1000 SKAW PARTITONED ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement-1,the unde ' e respoffiitdlity to tat s"Mit of the POWTS shown on the attached plans. <br /> Plumber's Name( SEP I IL; tAU . 5 e MP/MPRS Number TBusiness Phone Number <br /> Mel Ferguson dbIN6228 COUNTY LIN MPRS 224879 <br /> Plumber's Address(Stri <br /> 7'15-G3 -74 2 <br /> VJIL Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee B Date Issued ng Agent Sigoatur <br /> ° <br /> El Given Reason for Denial Issui <br /> $ 37s• / 8 <br /> IX.Conditions of ApprovaVRQeaso/ns forDisapproval / Q v <br /> Si/r I's Atld P'tl'T' Ot'/ /7S0 "°°d P4iN D'd P2Nsi�Lh �!f GZS. <br /> nD ECEuvE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1r2 z in size <br /> AUG 19 2016 <br /> BURNM COUNTY <br /> 20111 hlr- <br />