028-782-00-0100-SAN-2021-139 `,��-��,:ur�� COIIII[}� �
" � Safety and Buildings Division sawyer
'`o S P - � �� 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in t
_ � �]�/� � Ma ��,� 5�7�716� ��I (,� � ' Z
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Sanitary Permit Application State Transaction Number . N
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In accordance with s.SPS 383.21(2),Wis. Adm.Code,submission of ffiis form to[he appropriate govemmental 1
unit is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted project Address(if uiff rent than mailin�
to the Department of Safety and Professional Services. Personal information you provide may be used for secondary . —'
oses in accordance with the Privac Law,s.15.04 l m,Stats. �
1. Application Information-Please Print All Informafion 12415N Ross Rd 1�
Property Owner's Name Pazcel#
Teal Lake Dev LLC �2Qj._ �(��j_� _ �� (�(�
Property Owner's Mailing Address Property Location .
N2882 State Nwy I6
Govt.Lot 7
City,State Zip Code Phone Number %, '/4, Section 34
LaCrosse,W I 54601
T 42N; R 6 W
Il.Type of Building(c6eck 911 that apply) Lot#
� 1 or 2 Family Dwelling-Number of Bedrooms 2 Subdivision Name
Block#
� Public/Commercial-Describe Use
❑ City of
❑ State Owned-Describe Use CSM Number ❑ Village of
� Town of Spider lake
IQ.Type of Permit: (Check only one box on line A. Complete line B if applicable)
'4' � New System � Replacement ❑ Treatment/Holding Tank Replacement Only ❑ O[her Modificaiion to Existing System(explain)
System
B. � Permit ❑ Permit Revision ❑ Change of �Permit Transfer to List Previous Permit Number and Date Issued
Renewal Before Plumber New Owner �N�.O1i,,,� �
Ex iralion '
IV.T e of POWTS S stem/Com onentlDevice: Check all that a 1
� Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil
❑ Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain)
V.Dis ersaU'I'reatment Area Information: Quick 4 Plus
Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(s� Dispersal Area Proposed(s� System Elevation
300 .7 428.6 450.2 �(S 98.5/95.5 stepped
VI.Tank[nfo Capacity in Total #of Manufacmrer
Gallons Gallons Units s, � o v �
New Tanks Existing Tanks � c aUi � y � � �
0
a. U �n � v� i� C7 0..
Septic or Holding Tank g40 840 1 wieser � � � � �
°°S'°�cna"'� 500 500 1 wieser � � � � �
VII.Responsibility Statement- l,the uodersigned,assume responsibility for installation of the POW'TS shown oo the attached plans.
Plumber's Name(Print) Plumber's Sign re MP/MPRS Number Business Phone Number
Gerald Froemel � 950111 715-558-1138
Plumber's Address(Street,City,State,Zip Code)
13502W Froemel Rd Ha ward,Wl 54843
Vlll. o n /De artment Use Onl
(� � �1 �� Permit Fee Dat Issu 1 uin A ent SignaTure.'
;A rov d ❑ Disapproved
y c�b
❑Owner Given Reason for Denia( $ ( O�� S ZS ZUZ I
IX.Conditions of ApprovaUReasons for Diqppro�al ; •' •'_,1 ` !"j� i � �,�'
' .:,;,�� �l �J���
*^� ,� :,-;'��`
,i<<•..�.
� ;,� � N�AEFUNDS AFTER
`� � ���I��d UE OF PERMIT MAY 2 0 2021
�-'�i1� 185
Attach to complete plans for the system and submit to the County only on paper not less t6an 8 12 a ll inches in g�e1.ONING ADMiNISTRATION
SBD-6398(R. il/11),.,
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