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AR7AIpCounty <br /> � <br /> Industry Services Division Burnett <br /> 1400 E Washington Ave <br /> P.O. Box 7162 Sanitary Permit Number(to be filled in b Co.) <br /> Madison,WI 53707-7162 3)qN-at -0�80 <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. 15.04(1)(m),Stats. 29029 Bluff Lake Rd. ZLA 5180 <br /> 1. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> Laverne D.Mans Irrevocable Trust 07-036-2-40-17-09-5 05-006-014000 <br /> Property Owner's Mailing Address Property Location <br /> P.O.Box 593 <br /> Govt.Lot 6 <br /> City,State Zip Code Phone Number /<, Section 9 <br /> Hinckley,MN 55037 612-390-1735 e one) <br /> T40N R17E <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms Na Subdivision Name <br /> Na <br /> ❑Public/Commercial-Describe Use Block# <br /> Na ❑ City of <br /> ❑State Owned-Describe Use <br /> CSM Number ❑ Village of <br /> Na ® Town of Union <br /> II1.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. ❑ New System ❑ Replacement System ® Treatment/HoldingRe Tank Replacement Only El 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 State 60103/Co.11253 11/13/84 <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 /> 450 Rate(gpdsf) 643 700 -87.88 <br /> .7 <br /> VI.Tank Info Capacity in <br /> Y c � <br /> Gallons Gallons Units Manufacturer ro 5 U <br /> o Y p � <br /> New Tanks Existing Tanks ate, U ti <br /> Septic or Holding Tank 1 1000 1000 1 Wieser Concrete ® ❑ ❑ ❑ ❑ <br /> Dosing Chamber 1 600 600 1 1 1 ® ❑ ❑ ❑ ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P i re MP/MPRS Number Business Phone Number <br /> Luke Schmitz 884121 715-468-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> P.O.Box 160 Shell Lake WI 54871 <br /> VIII.Coun /De artment Use Only <br /> ❑ Approved ❑ Disapproved Permit Fee Date Issued I A nt Si <br /> ❑ Owner Given Reason for Denial $ 5 Q! <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> ECIEUVE <br /> HD <br /> J <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 112 ff <br /> 1 i es i s <br /> :J <br /> SBD-6398(R03/14) Burnett County <br /> Land Services Department <br />