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Commerce.Wl.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 BURNETT <br /> i sco n s i n Madison,Wl 53707-7162 Sanitary Permit Number(to be filled in by Co.) <br /> Department of Commeroe <br /> Sanitary Permit Application State Transaction Number In accordance with s.Comm.83.21(2),W is.Adm.Code,submission of this form to the appropriate governmental let ) <br /> unit is required prior to obtaining a sanitary permit. Note: Application fortes for state-owned POINTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary d�� <br /> purposes in accordance with the PrivacyLaw,s. 15.04(1 m,Stats. <br /> I. Application Information-Please Print All Information TRESURE ISLAND CT <br /> Property(Tuner's Name Parcel 4 <br /> MIKE PULK 07-012-2-40-15-12-5 15-750-033000 <br /> Property Owner's Mailing Address Property Location <br /> 21580 SOMERSET DOWNS LANE Govt.Lot <br /> City,State Zip Code Phone Number '/, Section 12 <br /> GALESVILLE,WI. 54630 (circle one) <br /> 11.Type of Building(check all that apply) Lot# T_40 N; R 15 W E or W <br /> X I or 2 Family Dwelling-Number of Bedrooms 3 25 Subdivision Name <br /> Block p TREASURE ISLAND ADD TO VOYAGER <br /> [I Public/Commercial-Describe Use <br /> ❑ City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> X Town of <br /> JACKSON <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) M7a5—D <br /> A. X New System Y El Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Chane of Plumber List Previous Permit Number and Date Issued <br /> Change ❑Permit Transfer to New <br /> Before Expiration Owner <br /> IV.Type of POWTS S stem/Com onent/Device: Check all that apply) <br /> X 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 /> V.Dis ersanreatment Area Information: <br /> Design Flow(go) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 0.5 900 917 <br /> 918'-98.4' <br /> VI.Tank Info Capacity in Total N of Manufacturer <br /> Gallons Gallons Units o o <br /> New Tanks Existing Tanks w i= �+ — <br /> U in vBi ii U a, <br /> Septic or Holding Tank 1000 1000 1 WIESER 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) Plumber' igneture MP/MPRS Number Business Phone Number <br /> GARY CHRISTMAN 1 248704 715 4664671 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> N 10015 MACK LAKE ROAD TREGO,WI.54888 <br /> VIII.Coun /De artment Use Only <br /> Approved 111 Disapproved Permit Fee ,Date Issued Issuin ent Si <br /> 11Owner Given Reason for Denial $�L25� //'r'JfMe 1A(( <br /> IX.Conditions of Approval/Reasons for Disapproval JUN 16 W1 <br /> BURNETT COUNTY <br /> ZONING <br /> Attach to completa plans for the system and submit to the County only on paper not less than 8 In x I l inches in size <br />