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/...,.A:-,-it «�Te -- — --, County <br /> `'.� �`Uv` Industry Services Division Giendr. <br /> I DS 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> t P S P.O. Box 7162 ,L <br /> e' ;4/' Madison, WI 53707-7162 s�-� -'I L"f <br /> ;e>; <br /> , AFt ,r. CVT-= 103 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit &a/1'0 <br /> is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to <br /> the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address(if differentnthan mailing address) <br /> .T)2 �5 <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. / 1� trZa. <br /> I. Application Information-Please Print All Information L,)t43 Th Z (1.4 )Visi) <br /> Property Owner's Name Parcel# 4110513 <br /> F-1/1i 1 IZQ% 67-*k,Z-3i-ri-Il.) 01-to-owl) <br /> PropertyOwner's Mailing Address <br /> Q Property Location <br /> 9(0 C_�-► ) l"r Govt.Lot <br /> City,Stat <br /> e <br /> p� In Zip Code Phone Number �q'/0, '/., Section li <br /> Lt- 51G r_ 1j3_ / ?5 33(40-4-11,, 7J T ✓ 1 N r' ; R (circle one) <br /> II.Type of Building(check all that apply) Lot# <br /> or 2 Family Dwelling-Number of Bedrooms/ Z Subdivision Name <br /> b rublic/Commercial-Describe Use VIZ Block 4 <br /> ❑ City of <br /> 0 State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> . ® Town ofG2�,,,�; �1 <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) �.(.C/V <br /> A. 0 New System Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of 0 Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV. <br /> I- <br /> lr tvon-Pressurized In-Ground 0 Pressurized In-Ground 0 At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design�Floow�(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) Systee /,�o+n, 13.1/ <br /> 2 Q <br /> r Z� Rate(gpdsf) . .'1 l 7 ! /95 4' /;�-C./ IJ.14 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of .0 °d <br /> Manufacturer o U '' <br /> New Tanks Existing Tanks Gallons Units `45,.. c 2 A 8 y a t <br /> ~r+Jtv <br /> Septic or Holding Tank C') /a2) 0) 95() .71))2) IJL-YE2 L'r,e)1r f/F ❑ 000 <br /> Dosing Chamber wY� 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> VII.Responsibility Statement- I,the undersigned,ass.me respibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum Sign. r MP/MPRS Number Business Phone Number <br /> Cory Jackson / 824339 715-566-2786 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 Black Brook Road,Webster,WI 54893 <br /> VIII.County/Department Use Only / <br /> proved 0 Disapproved Permit Fie00 �,a (ss 024 Issuing ent Sign re 7 <br /> (/ <br /> 0 Owner Given Reason for Denial $ 3/7 V �G / <br /> IX.Conditions of Approval/Reasons for Disapproval D <br /> id Vcs+ic, e t . l55 LS l/ l5 }, <br /> Si ffeg t kk.thatbrt *twit kv a* or about 13.944. _ 1 <br /> �e Utm 'KJot *LAM have Sft of oar. JUN 9 2020 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 he size <br /> Burnett Coln" <br /> SBD-6398(R03/14) _ Land Services Department <br /> $ I .7-1 (Z. -Z/67,,/ <br />