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Couffty <br /> �QI � Industry Services Division BURNETT <br /> 1400 E Washington Ave Sanitary Permit Number(to be fined in by Co.) <br /> P.O. Box 7162 <br /> Madison,WI 53707-7162 T;?Zn <br /> 5141�- <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 <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 different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15. 1 m,Slats. 25105 COUNTY LINE RD <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> CRAIG NAYLOR 07-024-2-39-14-36-101-"-011000 <br /> TAX#16381 <br /> Property Owner's Mailing Address Property Location <br /> 25105 COUNTY LINE RD <br /> Govt Lot <br /> City,State Zip Code-rI Phone Number 11$Ct14 OVIZ NE 1/4,NE 1/4, Section 36 <br /> NORTH PRAIRIE,WI 53153 (circle one) <br /> T39N R14EorW <br /> IL Type of Building(check all that apply) 2 Lot# <br /> 3® 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> El City of <br /> El Describe Owned-Desbe Use <br /> [40 <br /> SM Number ❑ Village of <br /> ACRES ® Town of RUSK <br /> III Type of Permit: (Check only one boa on line A Complete line B if applicable) <br /> A. ❑ New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <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 /> fV.Type of POWTS S stem/Com nent/Device: (Check all that apply) <br /> ® 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.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 643 650 >=85.2'<=86.2' <br /> .7 <br /> VL Tank Info Capacity in <br /> Gallons Total #of d c v <br /> Gallons units U uManufacturer o <br /> Nm Tanks 1 � <br /> .. �, <br /> U noinn i£ 5P. <br /> Septic or Holding Tank 3a0 060 l SKAW COMBINATION ® ❑ ❑ ❑ ❑ <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(Prim) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Mel Ferguson dba MPRS 224879 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIL Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit/Feer Date Issued Igsu6nog Agent Signature <br /> ❑ Owner Given Reason for Denial S / <br /> DL Conditions of Approval/Reasons for Disapproval D ECERSE <br /> NOV 6 2015 <br /> %ttach to complete plans for the system and submit to the County only on paper not less th 11 a O V In alae <br /> BURNETT COUNTY <br /> ZONING � <br /> f <br />