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Com ,vv1 9ov Safety and Buildings Division Catty <br /> 201 W.Washington Ave.,P.O.Box 7162scoBurnett <br /> t nCo1 sin <br /> OM Madison,WI 53707-7162 Sanitary er it N ma be filled in by Co.) <br /> ti <br /> T <br /> State Transaction Number <br /> Sanitary Permit Application � <br /> In accordance with s.Comm.83;21(2),Wis.Adm.Code,submission of this forth to the appropriate governmental ` <br /> mit 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 o('Commerce. Personal information you provide may be used fm secondary <br /> s in accordance withthePri,&cyL1ws. I5. t m,stats. 5611 Evergreen Lane <br /> 1. Application Information-Please Print All Information t^+, <br /> Property Owner's Name I Parcel N V <br /> Mike and Christy Fisher � �s <br /> 07-014-2-38-15-07-5 05-005A11000 <br /> Property Owner's Mailing Address Property location <br /> 119 Brush Street S. <br /> Govt.Lot 5 '/« '/w Section"/ <br /> City,State 1l,,��iAAin rnBn t. Zip Code Phone Number (circle one) <br /> Norwood INN J 55368 952-4542715 T 38 N; R 15 E or W <br /> II.Type of Building(checkall that apply) Lot N <br /> El or 2 Family Dwelling-Number of Bedrooms_ 2 Subdivision Name <br /> Block p <br /> ❑Public/Commercial-Describe Use ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> ❑Town of LaFollette <br /> III.Type of Permit: (Chmk only one boa on line A. Complete line B if applicable) 0jq-as-07—n-,;,— <br /> `k. ®New System ❑ Replacement System ❑Treatment(Holdtg Tank Replacement Only ❑Other Modification to Existing System(explain) <br /> B• 11 Permit Renewal ❑ Pemnit Revision ❑ Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Dale Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS S ste Com onent/Device: Check all that apply) <br /> ❑Non•Pressuriud t-Ground� 00Pressurized In-Ground ❑A4Grade ❑ Mound>24 m.of suitable soil ❑Mound<24 in.of suitable soil <br /> ❑Holding Tank ❑OtherDispersal Competent(explain) ❑Pretreatment Device(explain) <br /> V.Dis rsal/freatmeat Area Information: EZ Flow 1203H Eisa Ratingof 50 .ft <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) I Dispersal Area Required Is]) Dispersal Area Proposed(sf) System Elevation <br /> 300 .50 600 Eiss 600 98.25' +97.65' <br /> VI.Tank Info Capacity in Total 8 of Manufacturer <br /> o ti <br /> ' <br /> Gallons Gallons Units a O <br /> New Tanks Existing Tanks caw. o -4 <br /> Septic or Holding Tank 1000 1000 1 Wieser Concrete X <br /> Dosing Chamber 500 500 Combination X <br /> VII.Responsibility Statement- I,the undersigned.,assume reaponsibility for joliIanation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) 's MP/MPRS Number Business Phone Number <br /> Dayton Daniels MPRS#007086 715-349-5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Boz 326 Siren WI' 54872 <br /> IL County/De artmen6Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Issum m Signature <br /> ❑ Ownerwen Reason f Denial S���•�� �al <br /> IR Conditions of Approvyl/Reasons for Disapproval <br /> III' <br /> �-_' 8 2019 J <br /> Attack to complete plain for the system and submit to the County only on paper not Ion than 9 in 111 iocaesindln N E I IrCOUNTY <br /> 6Ur1 ZONING <br />