HomeMy WebLinkAbout012-640-20-5407-SAN-2021-389 �:�-`��'"'��� � Industry Services Division Counry _ � �
�� 4822 Madison Yards W1y Sawyer � .
� � Madison,WI53705
S p �� �� Sanitary Permit Number(to be filled in E
;> �, _ : � P.O. Box 7162 i
�'>� --� -,�•'� � Madison,WI 53 707-7 1 62 ����,� ��� �
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Sanitary Permit Application s`"`�T,��°"'�"°"�"",b"� �
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In accordance�vith SPS 383.21(2),Wis.Adm.Code,submission of this fonn to the appropriate governmental unit _� �
is required prior to obtaining a sanitary permit.Notc:Application forms for state-owned POWTS are submitted to Project Address(if different than mailin�
the Departmant of Safery and Professional Sercice,.Per,onal information you provide may be used for seconda�y 8487N, $499N 849�N RI �
pu�poses in accordance���i[h the Priv��cy Latv.s. I S,p4�I)(m),Stats. +
I.Application Information—Please Print All Information �-�
Prope�iy O��mer's Name Parcel#
Menard, Inc. �,2-64�-2�-54�8;�,2-G40-2�-54�5;0,2-64�-2�-54��
Property Ownei's Mailing Address Property Location
4777 Menard Dr ����.Lo� prt 4
Ciry,State Zip Code Phone Number
Eau Claire, WI 54703 _—_.�%.____��, se��;on20__ _
II.Typc of Building(check all that apply) Lot� T40 N �Z 06 �o�.W
�I or2 Family Dwclling—NumbcrofBcdrooms 4 _ � Suhdivision I�'ame
Block t?
�I'ublic/Commercial—Describe Use
❑('ity of
�Statc Owncd—Dcscribc Usc__ CSM Numba� Village of
� To��„�r Hunter -�'
37/109 #8550 ❑ — - — - �_ --- --
III.Type of POWTS Permit:(Check eiUier"New"or"Replacenient"and other applicable on line A. Check one box on line B.Coniplete line C if
ap licable.)
.4.
� '�fe,w eplacement System ther Modification to fixisung System(explain) �Additional Pretreaunent Unit(explain)
B' �F�olding Tank �In-Ground �At-Gade �✓ Mound Individual Site Design Other T�pc`exnlain)
(conventional)
C• ❑ReneN�al Befm�e �Revision �C'han<�c of Plumbcr �I ransfcr[o New Owner
List Previous Permit Number and Date[ssued
�-xp„��,o�, a � - ��-Y �/3I� �
IV.Dispersal/Treatment Area and Tank Information:
Dcsivn Flo�v(gpd) Design Soil Applica[ion Ratc(gpd/sf) Dispe�sal Arca Required(s� Dispersal Arca Proposed(st� Systcm Elcvatiun
600 1 .0/2.0 300 318.50 98.17
Capacity in Total #of Manufacturcr
Tank Infonnation Gallons Gallons Units p � V � � �
New Tanks Existing Tanks � o � � � p ro ;�
a U v� � v� i� U a
szE„"°'�"°�`�'"����"� 1250 1250 1 Wieser Concrete ✓
DosingCl�amber ]cJ0 �jQ 1 Wieser Concrete ✓ � � �
V.Responsibility Statement- I,the undersigned,assume respo ility for install i of the POW'1'S shown on the attached plans.
Plumbcr's Name(Print) Plumber's Si� re MP/MPRS Number I3usiness Phane Numher
Travis Butterfield � 652879 715-634-8176
Plumbei's Address(Strect,City,State,Zip Code)
14346W St. Rd. 77, Hayward, WI 54843
VI.Coun y/Department Use Only
Pcnnit Fcc Datc Issucd Is Agc t Signature
� ApP�v� ❑Disappro��ed S��� i2J � �
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❑Owner Givcn Reason for Denial � �� 7�
Conditions of Approval/Rcasons for DisaE�proval � �.�,;+�,,;���y'��
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Attach to complete p ans fm�[he system and submit to[he Count��onl}�on paper not Iess than 8�/2 x 11 mches in sne
�(,,P� � ��%'I� � �91 �� ZI��I NO REFUNDS AFTER
SBD-6398(R.03/21) �
18SUE OF PERMI7
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