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s•rKTiut� County <br /> Industry Services Division Burnett <br /> 't 0 1400 E Washington Ave <br /> P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) <br /> Madison,WI 53707-7162Ll <br /> ^�f <br /> `3 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this font to the appropriate governmental unit <br /> is required prior to obtaining a sanitary penint. 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(1)(m),Stats. 28623 BRIDGE RD <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name ParLx l 4 <br /> PATRICIA K KRIHA <br /> 07-012-240-15-13-5 05-001-023000 <br /> Property Owner's Mailing Address Property Location <br /> 2844 GLENHURST AVE S <br /> _ Govt.Lot I <br /> City,State Zip Code Phone Number V., 'A, Section 13 <br /> ST LOUIS PARK,MN 55416 (circle one) <br /> T40N15: RWEorW <br /> 11.Type of Building(check all that apply) Lot k <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 4 Subdivision Name <br /> ❑Public/Commercial-Describe Use Block 4 <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSMNumber ❑ Village of <br /> CSM V 2 P 93(4 170933) ® Town of Jackson <br /> III.Type of Permit: (Check only one box on line A. Complete line 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 10, <br /> Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber wner <br /> W.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) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed Is System Elevation <br /> 450 Rate(gpdsf) 642 658 93.5-92.8 <br /> .7 <br /> Vl.Tank Info Capacity in <br /> Gallons Total 4 of o <br /> Manufacturer <br /> New Tanks Existing Tanks Gallons Gilts <br /> P. U Z;ri w (7 rY <br /> Septic or Holding Tank x 1000 1 Wieser ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) her' ' ature MP/MPRS Number Business Phone Number <br /> Luke Schmitz 884121 715468-2434 <br /> Plumbers Address(Sheet,City,State,Zip Code) <br /> PO Rux 160 Shell Lake W'I 54871 <br /> III.Coun /De artment Use Only <br /> Appmvcd ❑ Disapproved Permit Fee Date Issued �-r Issuing Agent Signatu <br /> L/❑ Owner Given Reason for Denial $ 3 757 <br /> '6 7'a L <br /> IX.Conditions of Approval/Reasons for Disapproval RECEOVEn <br /> Attach to complete plans for the system and submit to the County only on paper not less than a 12 x 11 inch in <br /> BURNETT COUNTY <br /> SBD-6398(K03/14) ZONING <br />