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���vr� <br />Industry Services Division <br />1400 E Washington Ave <br />County <br />a(� <br />``�, <br />Sanitary Permit Number (to be filled in by Co.) <br />P.O. Box 7162 <br />Madison, WI 53707-7162 <br />Sanitary Permit Application <br />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 <br />Project Address (if different than mailing address) <br />purposes in accordance with the Privacy Law, s. 15.04 1 (m), Stats. <br />_ <br />°Z 7 GO'd <br />I. Application Information — Please Print All Information <br />Property Owner's Name <br />�nwd(Q,i) <br />Parcel # <br />0-7o�),-3 a `40l'4a4S-0s_00 0Q7 <br />Property Owner's Mailing Address <br />E <br />Property Location <br />I o ."J j `t' RD <br />Govt. LotyDl"S <br />'/4, a <br />City, State <br />Zip Code Phone <br />Number <br />/4, Section <br />a <br />IDA/ 4:- <br />L7 f <br />(circle <br />T 'i 'r O N R oro%)) <br />I Type of Building (check all that apply) Lot <br />2 Family Dwelling Number Bedrooms <br /># <br />Subdivision Name <br />or — of <br />❑ Public/Commercial —Describe Use Block <br /># <br />El City of <br />E]State Owned — Describe Use <br />❑ Village of <br />CSM <br />v6 <br />Number <br />[31 Town of 'SC -6 Tr <br />III. <br />Type of Permit: (Check only one box on line A. Complete line B if applicable) <br />A. <br />New System✓ <br />Replacement System <br />El Treatment/Hol ding Tank Replacement Only <br />El Other Modification to Existing System (explain) <br />B. <br />❑ Permit Renewal <br />❑ Permit Revision <br />❑ Change of <br />❑ Permit Transfer to New <br />List Previous Permit Number and Date Issued <br />Before Expiration <br />Plumber <br />Owner <br />y <br />IV. Type 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 />Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) <br />V. Dispersal/Treatment Area Information: <br />Design Flow (gpd) <br />Design Soil Application <br />Dispersal AreaRequired(sf) <br />Dispersal Area Proposed (sI) <br />System Elevation <br />0 � <br />Rate(gpdsfl f 1 <br />Ll d <br />�1 <br />VI. Tank Info <br />Capacity in <br />y <br />Gallons Total <br />Gallons <br /># of <br />Units <br />Manufacturer <br />v o <br />° <br />n <br />New Tanks Existing Tanks <br />I U <br />C7 <br />P. <br />Septic or Holding Tank <br />—7 0 <br />% <br />d e i <br />9 U <br />❑ <br />I ❑ <br />❑ <br />Dosing Chamber 1 <br />❑ ❑ <br />❑ <br />1 ❑ <br />❑ <br />VII. Responsibility Statement- I, the undersigned, assuWVr,sfd.siPilitY f installation of the POWTS shown on the attached plans. <br />Plumber's Name (Print) <br />Plumber's igna ad V <br />MP/MPRS Number <br />Business Phone Number <br />Dan Burch <br />253808 <br />715.416.1642 <br />Plumber's Address (Street, City, State, Zip Code) <br />N5921 County Hwy K Spooner WI 54801 <br />V II. County/De artment Use Only <br />Approved <br />❑ Disapproved <br />Permit FeeeD <br />Date Issued <br />Issuing Agent Sign ure <br />ElOwner Given Reason for Denial <br />$ &7S, <br />//-00 "17 <br />IX. Conditions/of Approval/Reasons for Disa roval / <br />/ <br />IUCwT 1",GT�/ D f wfTaIllWG40I <br />D MENE <br />70 <br />Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inched s'' tt IIV E 9j- v Lull L/BV y 1 COUNTY <br />SBD -6398 (R03/14) ZONING <br />OG <br />