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County <br /> Industry Services Division Burnett <br /> _ 1400 E Washington Ave <br /> � P.O. Box 7162 <br /> Sanitary Permit Number(to be filled in by Co.)P� .� <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis 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 maybe used for secondary Project Address(if different than mailing address) <br /> purposes in accordance with the Privacy Law,s. 15.04 1 m,Stats. 26226 W Lipsett Lake Rd <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Sara Delana Nelsen Living Trust 024311303100 <br /> Property Owner's Mailing Address Property Location <br /> 635 Barney St <br /> Govt.Lot <br /> City,State Zip Code Phone Number /4, /., Section 13 <br /> Owatonna,MN 55060 (circle one) <br /> T39N R14EorW <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms - 6&7 Subdivision Name <br /> Sunny Side Addition <br /> ❑Public/Commercial-Describe Use Block# <br /> El City of <br /> ❑State Owned-Describe Use <br /> CSM Number El Village of <br /> V 1 P 283 ® Town of Rusk <br /> III.Type of Permit: Check only one box on line A. Complete line B if a licable <br /> A. ® New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B El Permit Renewal El Permit Revision ❑Change of El Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <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) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 200 Rate(gpdsf) <br /> VI.Tank Info Capacity in <br /> Gallons Total #of �j N <br /> Manufacturer ro <br /> New Tanks Existing Tanks Gallons Units 2 c 2 P_ � � � 15 <br /> a. U n ,;, (A a. <br /> Septic or Holding Tank 2000 2000 1 Wieser ® Q ❑ <br /> Dosing Chamber ❑ ❑ EJ ❑ ❑ <br /> VII.Responsibility Statement- 1,the undersigned,assume respo bility r'nstal tion of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signatu MP/MPRS Number Business Phone Number <br /> Dan Burch 253808 715.416.1642 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 1118N Front Street Spooner WI 54801 <br /> VIII.Count /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issuing Agent Si n ture <br /> ❑ Owner Given Reason for Denial $ <br /> IX.Conditions of Approval/Reasons for Disapproval C(!y <br /> 1 D E CEOV E <br /> in3 is z� <br /> Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x �nr in*ASBD-6398(R03/14) Burnett County <br /> Land Services Department <br />