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County <br /> 1 Industry Services Division BURNETT <br /> 1400 E Washington Ave Sanitary Pert Number(to be filled in by Co.) <br /> ' P.O. Box 7162 <br /> Madison,WI 53707-7162 AM—A <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),Wis.Aden 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. 1482 COUNTY RD E <br /> L Application Information—Please Print All Information q <br /> Property Owner's Name Parcel# <br /> BRIAN&STACY HAUGEN 07-028-2-40-14-26-1 03-000-011000 TAX#18592 <br /> Property Owner's Mailing Address Property Location <br /> 14050 4901"ST <br /> Govt.Lot <br /> City,State Zip Code Phone Number SW 1/a,NW 1/s, Section 26 <br /> PINE ISLAND,MN 55963 507 208 0791 (circle one) <br /> T40N R14WEorW <br /> EI.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms Subdivision Name <br /> 38.66 ACRES <br /> ❑Public/Commercial-Describe Use Block# <br /> ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number El Village of <br /> ® Town of SCOTT <br /> IIL 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 ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Plumber Owner <br /> IV.Type of POWTS S stem/Com nent/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 /> 600 Rate(gpdsf) 858 875 <93.3'»2.3'STTE ALTERED <br /> .7 <br /> Vt Tank Info Capacity in <br /> s.3 C o U <br /> Gallons Total #of Gal Units Manufacturer U 'pp <br /> New Tanks Existing Tanks :Vm� y ty <br /> Septic or Holding Tank 750/500 1250 1 SKAW PARTTIONED ® ❑ ❑ ❑ 1 ❑ <br /> Dosing Chamber ❑ ❑ ❑ ❑ 1 ❑ <br /> VEI.Responsibility Statement-I,the undersigned,assume responsibility for Installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) `, i ( MP/MPRS Number Business Phone Number <br /> MEL FERGUSON dba M&K SEPT d r ''lair, MPRS 224879 <br /> Plumber's Address(Street,City, ER, WI �801 <br /> VEIL Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issui//ng'Agent/.§ignature <br /> ❑ Owner Given Reason for Denial $ �.� �' �S'Z� <br /> L,J <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> D Ek�M0 <br /> n APR Y <br /> 7021 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 z ches in size <br /> umett County <br /> Land Services Department <br />