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0„.0 n,F,,, County <br /> Industry Services Division Burnett <br /> $ , 1400 E Washington Ave Sanitary Permit Number(to be filled in byCo.), <br /> P S . P.O.Box 7162 SAN-at_.z04 G N o Z <br /> s; Madison,WI 53707-7162 <br /> - _, csi-.Il —.93/e, <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. 1089 County Road E Spooner WI 54801 <br /> I. Application Information—Please Print All Information 1 5 3 <br /> Property Owner's Name Parcel# <br /> Gerald J Hamden 07-028-2-40-14-24-5 05-005-027000 <br /> Property Owner's Mailing Address Property Location <br /> 20 2nd St NE Unit 804 <br /> Govt.Lot 5 <br /> City,State Zip Code Phone Number /4, /4, Section 24 <br /> Minneapolis,MN 55413 (circle one) <br /> T40N ; R14EorW <br /> II.Type of Building(check all that apply) Lot# <br /> ® I or 2 Family Dwelling—Number of Bedrooms 1 Subdivision Name <br /> 0 Public/Commercial—Describe Use Block 4 <br /> 0 City of <br /> O State Owned—Describe Use <br /> CSM Number El Village of <br /> V 3 P 35 ® Town of Scott <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System ® Replacement System El Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 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 System/Component/Device: (Check all that apply) <br /> ® Non-Pressurized In-Ground 0 Pressurized In-Ground ❑ At-Grade 0 Mound>24 in.of suitable soil 0 Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) V[Pretreatment Device(explain) / © r. <br /> Mi <br /> V.Dispersal/Treatment Area Information: C�i <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 450 Rate(gpdsf) 282 332 91-95 <br /> 1.6 <br /> VI.Tank Info Capacity in <br /> :: <br /> Gallons Total 4 ofn 0 ° .2 <br /> Manufacturer i o U c, <br /> Gallons Units c �: 1? I ,n 14 <br /> New Tanks Existing Tanks a U in v, vn t+- C7 a <br /> Septic or Holding Tank 1000 1000 1 Wieser ® ❑ 0 0 0 <br /> Dosing Chamber 600 6 0 I Wieser z 0 0 0 ❑ <br /> VII.Responsibility Statement- I,the undersigned,assume resp sibil'ty for installation of the POWTS shown on the attached plans. _ <br /> Plumber's Name(Print) Plumber's Sign re 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.County/Department Use Only <br /> ❑ Approved 0 Disapproved Permit F e � Date Issue I uI ent •� at /� <br /> ❑ Owner Given Reason for Denial $ L1 , 113 . TECIEDWIE <br /> t .IX.Conditions of Approval/Reasons for Disapproval 5se,cr eAe,vu. ton m.)S) le, gq.5 . oc less / <br /> Ina 'No v\ci;n . /`1Js-\ bc- 2' above, 0 4\IJA SEP 2 7 2021 <br /> 6l.\W M ‘5 190. l0 . Conkooc- lines ace. qq 2- gCi6 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 In x 1 inch Inartssurnett County <br /> /a5oo Land Services Department <br /> SBD-6398(R03/14) `t"� ' <br />