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Industq Services Division County <br /> 4822 Madison Yards Way BURNETT <br /> Madison,Wl 53705 Sanitary Permit Number(to be filled in by Co.) <br /> : P.O.Bo 7162 N—a�-333 G40(o7l <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transaction Number <br /> In accordance with SPS 383.21(2),W'is,Adin.Code,submission of this tort to the appropriate governmental tubs NA <br /> is required prior to obtaining a sanitary permit.Note:Application fonts for state-owned POWTS are submitted to Project.Address(if different than mailing address) <br /> the Department of Safety and Professional Ser%ices Personal mtormation you provide ma\be used for secondan 5505 BRIGGS LAKE LANDING <br /> purposes in accordance with the Privacy Law,s. 15.(A(1 Xm),Scats. <br /> 1.Application Information-Please Print All Information <br /> Property O,kner's Name Parcel 2- 7 1�j <br /> BRIGGS LAKE FAMILY CABIN LLC 07-032-2-41-15-29-4 02-000-011000 <br /> Property Owner's Mailing Address Property location <br /> 14601 MINNEHAHA PL _ <br /> j Goys.Lot <br /> Ciry.Spite lip Code Phone Number <br /> WAYZATA, MN 55391 j .-.__N_W—aSE__- Section 29__---- <br /> 11.Type of Building(check all that apply) Lot a �� 41 K 15 f:nr <br /> z1 or)Familv Dwelling—Number of Bedrooms_BA+HROOIAINOFFICE NA ! Subdivision Name <br /> Block# NA <br /> ['ubiiclCommercial-Describe Use — _ <br /> NA __j❑C�ityc,f <br /> ----- --------- <br /> LState Owned-Describe Use _..- CSM Number M11" <br /> .Have of <br /> NA ownof SW1SS <br /> III.Type of P0V6'TS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.(:omplete line C 1f <br /> applicable.) <br /> � ✓ New System []Replacement System Other Modification to Existing System(explain,) Additional Pretreatment Unit(explain) <br /> B. Ellolding 7ank zIn-Ground 0yt-Grade Mound Individual Site Design Other FYp e(explainI <br /> (cone'enuonal) <br /> ist Previous Permit Ntanher and Date Issued <br /> C. ❑Renewat Before i�Revision ,hange of Number �Trmistea to New Oe�rer) <br /> Expiration <br /> IV.Dispersallfreatment Area and`rank Information: <br /> Design Flow(gpd) Design Sod Application Rate(gpolst) Dispersal Area Required(st) Dispersal Area Proposed(st) System Flevation <br /> 150 0.7 214.29 ! 225 96.00 FT. <br /> Capacity in Total if of Manufacturer <br /> Tank Information Gallons Gallon hits <br /> 1'�w"ranks Fxrsnug Tanks <br /> Scptic or Holding Tank 540 — 540 1 1 INFILTRATOR <br /> Dosmg Chamber =I = <br /> o it' <br /> V.Responsibility Statement- 1,the undersigned,assu a resp ,for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb Siena tr R4PiMPRS Number Business Phone titrrnher �- <br /> CORY J. JACKSON 824339 L 715_866-8944 <br /> 6 <br /> Plumber's Address(Street.City.State.Tip Code) - _-- <br /> 9306 BLACK BROOK RD., WEBSTER, WI 54893 <br /> N7.CountyfDepartment Use Only _ _ <br /> �APFroycd ❑Disapproved Permit Fee Date Issued Issuin e Signat <br /> LJ OwnerGiyen Reason for Denial <br /> Conditions of Approval/Reasons for Disapproval <br /> rk,� <br /> {l i5'�a 15c� � � � � <br /> in , <br /> Attach to complete plans for the system and submit to the County only on paper not less than s ttt N t 1 n sis ' - <br /> SRD-6 399 I R.0"21) Burnett County <br /> Land Services Department <br />