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Attacn to complete pians for me system ana summit to the Uounty only on paper not less than 8 112 x 11 inches inttee U L=/ / <br />BURNETT COUNTY <br />ZONING <br />County <br />0 <br />0 <br />Industry Services Division <br />1400 E Washington Ave <br />BURNETT <br />it <br />I $ <br />Pa <br />P.O. Box 7162 <br />Sanitary Pe Nu ber (to be filled in by Co.) <br />'� <br />Madison, WI 53707-7162 <br />Ay� ON COMPUTE <br />SCANNED <br />S <br />Sanitary Permit Application <br />State Transaction Number <br />NA <br />In accordance with SPS 383.21(2), Wis. Adm. Code, submission ofthis 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 />Project Address (if different than mailing address) <br />the Department of Safety and Professional Services. Personal information you provide may be used for secondary <br />purposes in accordance with the Privac • Law, s. 15.04(1 m), Stats. <br />BENT TREE PASS _1r 3 S S 7 <br />I. Application Information - Please Print All Information <br />Property Owner's Name <br />Parcel # <br />LARS FERRER <br />07-012-240-15-13-5 15-045-029000.5 CARES <br />Property Owner's Mailing Address <br />Property Location <br />654 GALLOWAY STREET <br />Govt. Lot <br />'/a, '/a, Section 13 <br />City, State <br />Zip Code <br />Phone Number <br />NORTH PRAIRIE, WI <br />7 <br />53153 <br />262 470 3903 <br />(circle one) <br />T40N R15WEorW <br />H. Type of Building (check all that apply) <br />Lot # <br />® 1 or 2 Family Dwelling - Number of Bedrooms <br />19 <br />Subdivision Name <br />BENT TREE ADD TO VOYAGER VILLAGE <br />Block # <br />❑ Public/Commercial - Describe Use <br />❑ City of <br />❑ State Owned - Describe Use <br />❑Village of <br />CSM Number <br />_ <br />® Town of— � . <br />III. <br />Ty a of Permit: (Check only one bog on line A. Complete line B if applicable) <br />A. <br />New System <br />®Replacement System <br />❑Treatment/Holding Tank Replacement Only <br />❑ Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />Owner <br />IV. <br />Type of POWTS S stem/Com nent/Device: (Check all that apply) <br />0 Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil <br />C3 Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application <br />Dispersal Area Required (sf) <br />Dispersal Area Proposed (sf) <br />System Elevation <br />300 <br />Rate(gpdsf) <br />432 <br />450 <br />-87.0'-88.0' <br />.7 <br />VL Tank Info <br />Capacity in <br />Gallons <br />Total <br /># ofn 2 <br />Manufacturer 2 U <br />New Tanks <br />Existing Tanks <br />Gallons <br />Units <br />C <br />a`. ` j <br />w p ^ <br />U <br />a <br />Septic or Holding Tank <br />800 <br />800 <br />SKAW <br />® ❑ <br />❑ ❑ <br />❑ <br />Dosing Chamber <br />❑ ❑ <br />❑ ❑ <br />❑ <br />VII. Responsibility Statement- I, the undersigiked, assume responoility for installation of the POWTS shown on the attached plans. <br />Plumber's Name (PrinIJI&K SEPTIC & EX "attu"' <br />MP/MPRS Number <br />Business Phone Number <br />Mel Ferguson dba L NCC <br />MPRS <br />224879 <br />AA pp <br />Plumber's Address (Street, �e�C*A 548 <br />715-635-7482 <br />VIII Coun /De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit Fee <br />jDate Issued _/ <br />I uing Ag <br />t Signature <br />1315 3 7 S <br />❑ Owner Given Reason for Denial <br />$)/ -� <br />L5�%- / <br />IX. Conditions of Approval/Reasons for Disapproval <br />/\c�. }ht�hRr) <br />Q <br />.AtRI <br />���-h s y s-}r=�'1 ��� �.,��� <br />MUSE <br />6 2017 <br />Attacn to complete pians for me system ana summit to the Uounty only on paper not less than 8 112 x 11 inches inttee U L=/ / <br />BURNETT COUNTY <br />ZONING <br />