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Industry Services Division County <br /> 4822 Madison Yards Way tp <br /> ?si S. Madison,WI 53705 Sanitary Permit Number(to filled in by Co.) <br /> '$ P.O.Box 7302 i (a. / /4 <br /> Madison,WI 5302 -g3 <br /> (9R <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 Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary Rd4 CO <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. ��' <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Stephen Christner <br /> 15553 <br /> Property Owner's Mailing Address Property Location <br /> W9187 County Rd.A Govt.Lot <br /> City,State Zip Code Phone Number <br /> Spooner,WI 54801 SW /, SW 1/4, Section 01 <br /> II.Type of Building(check all that apply) Lot# T 39 N R 14W <br /> x 1 or 2 Family Dwelling-Number of Bedrooms 3 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑City of <br /> 0 State Owned-Describe Use <br /> CSM Number 0 Village of <br /> ❑Town of Rusk <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. <br /> ❑ New System peplacement System ❑ Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B. ❑ Holding Tank KIn-Ground ❑At-Grade ❑ Mound ❑ Individual Site Design ❑ Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑Change of Plumber ❑ Transfer to New Owner <br /> List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 .7 643 660 96 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o <br /> ce <br /> New Tanks Existing Tanks c .2 A A <br /> U n ii C7 G <br /> Septic or Holding Tank <br /> 1000 1000 1 Weiser x <br /> Dosing Chamber <br /> V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb is Signature Qz),iMP/MPRS Number Business Phone Number <br /> Kelly Ferguson 1 Oi/l, 224069 715=416-4597 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> W9502 Dock Lake Road Spooner WI 54801 <br /> VI.County/Department Use Only <br /> Approved 0 Disapproved Permit Fee D tee Is ued Issuin Ag Signatur <br /> 0 Owner Given Reason for Denial $375 co 6/ (?) • ` <br /> Conditions of Approval/Reasons for Disova <br /> j'�'Iee4 a �� 5e e cn /t SP5 33 C MEIN <br /> , -,A 5 ( o o o , <br /> �Aee , DelecAe4Q -hive aF fry each"Ipe, u5 ,IUN 01 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 1 inches a urnrtt County <br /> Land Service!Department <br />