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9'rnar41eti>F Industry Services Division County <br /> J9 4822 Madison Yards Way 53705 Burnett <br /> PO Box 7162 aarntary Permit Number(to be filled in by Co.) <br /> Madison,WI 53705-7162 �}J�I <br /> Sanitary Permit Application State Plan Review Number <br /> In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit PWTS— C <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 Servies.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(I)(m),Slats. 6821 FLOWAGE DR <br /> I. Application Information—Please Print All Information <br /> Property Owner's Name Parcel# <br /> Susan M Schmitz Trust 07-032-2-41-16-35-5 05-003-025110 <br /> Property Owner's Mailing Address Property Location <br /> 4560 FABLE HILL PKWY N <br /> City,State Zip Code Phone Number Govt.Lot <br /> Hugo MN 55038 /4, Section_35_ <br /> (circle one) <br /> II.Type of Building(check all that apply) Lot# T 41 N" R 16 E or W <br /> 1 or 2 Family Dwelling—Number of Bedrooms_5 3 Subdivision Name <br /> Block# <br /> ❑Public/Commercial—Describe Use <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number ❑ Village of <br /> 4931 VOL 27 P 276 11 Town of <br /> DOCUMENT 460754 Swiss <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> `4" ❑New System XrReplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) <br /> B. ❑ Permit Renewal ❑ Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued <br /> Before Expiration Owner <br /> IV.Type of POWTS System/Component/Device: Check all that a 1 <br /> V 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.Dis ersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 750 0.7 1071 1098 92 <br /> Vl.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units o <br /> New Tanks Existing Tanks o Y <br /> a U in v� v. C7 ii <br /> Septic or Holding Tank X 1645 1 Wieser X <br /> Dosing Chamber x 1000 1 Wieser X <br /> VII.Responsibility Statement- 1,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number <br /> Luke Schmitz 894121 715-520-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 160 Shell Lake WI 54871 <br /> VIII.Coun /De artment Use Only <br /> Approved ❑ Disapproved Permit Fee Date Issued Issui g gent S.gnat <br /> Ae <br /> ❑ Owner Given Reason for Denial <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 t 1 es i ZQL 1 <br /> Burnett County <br /> SBD-6398(R.04/19) Land Services Department <br />