Laserfiche WebLink
County <br /> 1 Industry Services Division BURNETT <br /> 1400 E Washington Ave s <br /> '= P.O. Box 7162 aniUry Ism miCNumber(to be filled in by Co.) <br /> ., Madison,WI 53707-7162 sAN�C gr <br /> e- �[- Las/ z.- <br /> Sanitary Permit Application 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 Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.0 1 m,Stats. EAST OF 1288 S.LIPSETT LAKE RD <br /> L Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> PAUL&REBECCA BESEMAN 07-024-2-39-14-13-5 05-003 18000 TAX#15916 <br /> Property Owner's Mailing Address Property Location <br /> 12400 SKYLINE DR N <br /> Govt.Lot 3 <br /> City,State Zip Code Phone Number 1/s, 1/4, Section 13 <br /> BURNSVILLE,MN 55337 651 336 2211 (circle one) <br /> T39N R14WEorW <br /> IL Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms 1 Subdivision Name <br /> #1316 V13 P10 DOC#265143 <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑State Owned-Describe Use ❑ City of <br /> CSM Number ❑ Village of <br /> ® Town of RUSK <br /> III a of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ® New System ❑ Replacement System <br /> y ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explaiq) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S stern/Com nent/Device: (Check all that a 1 ) <br /> ® Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil <br /> ❑ HoldingTank El Mound<24 in.of saihble soil <br /> ❑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(sf) System Elevation <br /> 300 Rate(gpdsf) 432 450 >--90.O'<--90.6' <br /> .7 <br /> VL Tank Info Capacity in <br /> G <br /> Gallons Total #of Manufacturer o U <br /> New Tanks Existing Tanks Gallons Units v a <br /> Septic or Holding Tank 700/300 1000 1 SKAW Partitioned ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber ❑ ❑ ❑ 10 <br /> VIL Responsibility Statement-I,the undersigned,assume responsihility for instagation of the POWTS shown on the attached plans. <br /> Plumber's Name(Prim) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Mel Ferguson MPRS 22481 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> VIIL Coun /De artment Use Only <br /> IX Approved ❑ Disapproved Permit Fee , Date I,s/sued Issuing Agent Signature <br /> El Owner Given Reason for Denial $ 37`r S 7'Z� <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> J <br /> Attach to complete plans for the system and submit to the Cataty only on paper not less than 81/2 1 i4b es in size <br /> Burnett County <br /> Land Services Department <br />