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eommerceml.gov Safety and Buildings Division Comity <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> i sco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> .aperbnnMwc 5403047 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with s.Comm.83.21(2),W is.Adm.Code,submission of this form to the appropriate governmental V, reaJ <br /> unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary -y— <br /> purposes in accordance with the PrivacyLaw,s.15.04(l m Slats. 3024 Aspeft re4 <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel' <br /> Joan White Mo� �g�'3�5�� <br /> 07-028-2-40-14-07-515-706-082000 <br /> Property Owner's Mailing Address Property Location <br /> 1884 121`.Street <br /> Govt.Lot 'A,'/S section 7 <br /> City,State Zip Code Phone Number (circle one) <br /> Balsam Lake WI 54810 715-825-1185 T 40 N; R 14 E or W <br /> 11.Type of Building(check all that apply) Lot# <br /> 0 1 or 2 Family Dwelling-Number of Bedrooms 2 78 Subdivision Name <br /> Spring Green Add.To Voyager Village <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> a Town of Scott <br /> 111.Type of Permit: (Check only one boa 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. 11 Permit Renewal ❑ Permit Revision <br /> ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that apply) <br /> P Non-Pressurized In-Ground ❑Pressurized In-Gromtd ❑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 ersaOTreatment Area Information: Quick 4 Standard-W Eisa Rating of 20.00 sq.ft. <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(s0 1 System Elevation <br /> 300 .7 429 440(Elsa) 96.00' <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units n o$ v <br /> New Tanks Existing Tanks <br /> a U rn H rn w C7 P. <br /> Septic or Holding Tank 750 750 1 Wieser Concrete X <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) Plum Signature MP/WRS Number Business Phone Number <br /> Robert Carlson <br /> MPR S#135655 715-653-2500 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 3572 115th St. Frederic WI 54837 <br /> VIR.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing ent ignature <br /> ❑Owner Given Reason for Denial <br /> IX.Conditions of ApprovalfReasons for Disapproval <br /> Attach to eompkee plans for the system and sabma to the County only on paper not las than 8 to x 11 inches in sin <br /> SBD-6398(R 02/09)Valid thin 02/11 <br />