Laserfiche WebLink
County <br /> 01 " <br /> Industry Services Division BURNETT <br /> i, 1400 E Washington AveP.O. BOX 7162S r-n�� (to be idled in by Co.) <br /> tMadison,WI 53707-7162 �'�f <br /> ON s <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 requited 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.15.04(l m,Stats. BENT TREE PASS <br /> L Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> LARS FERRER 07-012-2-40-15-13-5 15-045-029000.5 CARES <br /> Property Owner's Mailing Address Property Location <br /> 654 GALLOWAY STREET <br /> Govt Lot <br /> City,State Zip Cade Phone Number '/4, V4, Section 13 <br /> NORTH PRAIRIE,WI 53153 262 470 3903 (circle one) <br /> T40N R15WEorW <br /> IL Type otBuilding(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 19 Subdivision Name <br /> BENT TREE ADD TO VOYAGER VILLAGE <br /> ❑Public/Commercial-Describe Use Block# <br /> [I City of <br /> El State Owned-Describe Use <br /> CSM Number ❑ Village of _ <br /> ® Town of- :4l. J(S C k j1 <br /> III Type of Permit: Check only one box on line A Complete tine 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 /> IV.Tylx of POWTS System/Component/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 /> C3 Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersanreatinent Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(st) Dispersal Area Proposed(sf) System Elevation <br /> 300 Rate(gpdst) 432 450 >=87.0'<=88.0' <br /> .7 <br /> VL Tank Info Capacity in <br /> Gallons Total #Of <br /> Manufacturerh ° <br /> New Tanks Existing Tanks dons Units U to in fi•, 0 P. <br /> Septic or Holding Tank 800 800 SKAW ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement-I,the undemilKed,assume responilitIdIfty for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Priv&K SEPTIC & EX MP/MPRS Number Business Phone Number <br /> Mel Fer n dba a, L N p MFRS 224879 <br /> a7s vS <br /> Plumber's Address(Street, CR548 <br /> 715-635-7482 <br /> VUL CountyADepartment Use Only <br /> Approved ❑ Disapproved Permit F /Date^IIssued ing Ag Signazure —/ <br /> ❑ Owner Given Reason for Dermal $ S D `ti.6-'�7 1 1 S"3 ✓ S <br /> DL.Conditions of Approval/Reasons for Disapproval 00 <br /> .111N 26 017 <br /> Attach to complete plans for the system and subma to the County only on paper not less than 8 V2 x 11 inches io <br /> BURN U <br /> ZING NTY <br />