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Safety and Buildings Division County 1 <br /> Visconsin 201 W.Washington Ave.,P.O.Box 7162 ovr1ra Madison,W1 53707-7162 Sanitary Permit Number(to be filled in by Cut <br /> _-Department of Commerce (608)266-3151 _5S i 274 <br /> Sanitary Permit Application State Plan I D Numbers <br /> In accord with Comm 83 21,Wis.Adm.Code,personal information you provide L- "4 V k V i fto �l( n`� <br /> may be used for secondary purposes Privacy Law,s15.04(l Kin) Project Address(if different than mailing address) JI <br /> 1. Application Information-Please Print All Information N. Lipsett Lake Rd. <br /> Property Owner's Name Parcel# Lot# Block# <br /> Roger Brede o7-oz4-2.39-lr*-/2-5 o5-co1•oj1co <br /> Property Owner's Mailing Address Property Location <br /> 26629 N Lipsett Lake Rd. CID <br /> V-State Zip Code Phone her µ i�„OT 1, �, Section 12 <br /> Num <br /> Spooner Wl 54801 3914(circleone) <br /> II.Type of Building(check all that apply) T_N, R r , <br /> ❑+ I or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name CSM Number <br /> Public/Commercial-Describe Use r�t,. <br /> ❑State Owned-Describe Use QCity ❑Village 01ownship of Rusk <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A_ 0 New System ❑ Replacement System ❑Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System <br /> B. 11ermit Renewal ❑ Permit Revision ❑Change of T❑Permit Transfer to New <br /> List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS system: Check all that apply) <br /> 0 Non-Pressurized In-Ground 0 Mound>24 in.of suitable soil 0 Mound<24 inof suitable soil ❑At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑Holding Tank 0 Peat Filter ❑Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber 0 Drip Line 0 Gravel-less Pipe 0 Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsn Dispersal Area Required(st) Dispersal Area Proposed(st) System Elevation <br /> 450 .7 643 660 97.5 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic <br /> Gallons Gallons of Units Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks <br /> Septic or Holding Tank 1000 1000 1 Wieser x <br /> Aerobic Treatment Unit <br /> Dosing Chamher <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) u tier's Signature MP/MPRS Number Business Phone Number <br /> Kelly Ferguson 1224069 715-635-2887 <br /> Plumber's Address(Street,City,State,Zip C ) <br /> W9502 Dock Lake Road Spooner WI 54801 <br /> VI .Cour /De artment Use Onl <br /> Approved ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing a ignature tamps) <br /> Surcharge Fee) n/� <br /> El Owner Given Reason for Denial .3�SJh,tJ )7/* <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> flu <br /> Attach complete plans(to the County only)for thesystemon papernorlees Man ina zII inchesinsiMAY <br /> 17 <br /> 2012 <br /> SBD-6398 (R. 01/03) BURNETT C+OUNN <br /> ZONING <br />