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commerceml.gov Safety and Buildings Division County <br /> 201 W.Washington Ave.,P.O.Box 7162 Burnett <br /> sco n s i n Madison,WI 53707-7162 Sanitary Permit Number(to be filled in by Co,)i <br /> Department M Commerce 558 8 <br /> Sanitary Permit Application State Transaction Number Uri <br /> accordance with s.Comm.83 2](2),Wis.Adm.Code,submission of this form to the appropriate governmental t f1sA l✓ GA <br /> unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address(if different than mailing address) <br /> submitted to the Department of Commerce. Personal information you provide may be used for secondary fz <br /> purposes in accordance with the Privacy Law,s. 15.04 I m,Stats. 24493 Anchor Inn Road <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel#,e7K9 is r qy-i2 ro S•900 <br /> Ray Nordquist LIZ, 07-014-2.38.15-054 04-000-011000 <br /> Property Owner's Mailing Address Property Location <br /> 14127 Fondant Ave <br /> Govt.Lot <br /> City,State Zip Code Phone Number SE '/.,SE '/., Section 5 <br /> Hugo 55038 651407.8854 (Check One) <br /> II.Type of Building(check all that apply) Lot# <br /> T38 N; R 15 ❑E ❑� W <br /> ❑✓ l or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> City of <br /> ❑State Owned-Describe Use CSM Number E] Village of <br /> ❑✓ Town of LaFollette <br /> 111.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. New System Replacement ❑✓ Treatment/Holding Tank Replacement Only Li Other Modification to Existing System(explain) <br /> System <br /> B. Permit Permit Revision Change of Permit Transfer to List Previous Permit Number and Date Issued <br /> ° <br /> Renewal Before Plumber New Owner <br /> Expiration <br /> IV.Type of POWTS S stem/Com onent/Dev1ce: Check all that e I <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 Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer Material <br /> Gallons Gallons Units <br /> New Tanks Existing Tanks <br /> Septic or Holding Tank 750 750 1 1 Wieser Concrete Prefab Concrete <br /> Dosing Chamber <br /> VII.Responsibility Statement-I,the undersigingril,assu e r 021bility for i allation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) u i MP/MPRS Number Business Phone Number <br /> Dayton R Daniels MPRS#007086 715.349.5533 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 326 Siren,WI 54872 <br /> VIII.County/Department Use Only <br /> _ Approved _ Disapproved Permit Fee Date Issued Issuing A t ignature <br /> ✓ _Owner Given Reason for Denial $ 3 5W ��4-9 <br /> Zny2 <br /> IX.Conditions of Approval/Reasons for Disapproval JJ <br /> Srw6k. featk Reoua*,"t only. <br /> Ertl ae or n6(rcafe. 4-40fc G+a//.r„ J%9 OCKl& -D 3g41$6: <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 to x it Inches in size <br /> SBD-6398(R.01/07)Valid thru 01/09 <br />