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Safety and Buildings Division County <br /> 201 W.Washington Ave., P.O. Box 7162 <br /> �������� Madison, W1 53707-7162 Sanitary Permit Number(to he filled in by Co.) <br /> Department of Commerce (608)266-3151 f <br /> Sanitary Permit Application State Plan`D./"umber <br /> In accord with Comm 83.21,Wis.Adm.Code,personal information you provide CDO nG Y ,QUI e,14) <br /> may be used for secondary purposes Privacy Law,sl 5.04(L)(m) Pr i c Address ifd�iiff rent than mailing address) <br /> 1P32�West �t.Kc�. <br /> 1. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# Lot N Block k <br /> Bruce & Laura Bray (Tall Timbers Resort) Govt. 3 <br /> Property Owner's Mailing Address Property Location <br /> N4811 Rainbow Drive <br /> City,State Zip Code Phone Number '1. Section 25 <br /> Spooner WI 54801 40 1 <br /> 4(circle one) <br /> H.Type of Building(check all that apply) T N; R r ✓ <br /> ❑� I ort Family Dwelling-Number of Bedrooms 2 Subdivision Name CSM Number <br /> ❑Public/Commercial-Describe Use <br /> ❑State Owned-Describe Use []City ❑Village '❑Township of Scott <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable)Q ,p3,8- _ fir. _0' <br /> A. <br /> ❑ New System 0 Replacement System ❑ Treatment/Holding Tank Replacement Only 13 Other Modification to Existing System <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New 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 ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ At-Grade ❑ Single Pass Sand Filter ❑ <br /> Constructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑Peat Filter ❑ Aerobic Treatment Unit ❑Recirculating Sand Filter ❑ <br /> Recirculating Synthetic Media Filter ❑Leaching Chamber 0 Drip Line (3 Gravel-less Pipe ❑Other(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(st) Dispersal Area Proposed(sn System Elevation <br /> 300 .7 428 440 98.00 <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 7550 750 1 Wieser X <br /> Aerobic Treatment Unit <br /> Dosing Chamber <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) I tier's Signatur MP/MPRS Number Business Phone Number <br /> Kelly Ferguson 224069 715-635-2887 <br /> Plumber's Address(Street,City,State,Zip C9de) <br /> W9502 Dock Lake Rd. Spooner WI 54801 <br /> VI .County/,Department Use Only <br /> Approved El Disapproved Sanitary Fermi[Fee(includes Groundwater Date Issued Issuing n ignature amps) <br /> Surcharge Fee) 9� J <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach complete plans(to the County only)for the system on paper not less than 81/2 x 11 inches in size <br /> SBD-6398 (R. 01/03) <br />