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.c0As71MF i, Industry Services Division ' County <br /> i \IY 4822 Madison Yards Way 53705 Burnett <br /> Z"` S PO Box 7162 Sanitary Permit Number(to be filled in by Co. <br /> P Madison,WI 53705-7162 SCJ _3tib 040(077 <br /> '1)--, <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(1)(m),Stats. 27452 E CONNORS LAKE RD <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> DAVID M&NICOLE R JANAS 020433602300 <br /> \q0 <br /> C1 <br /> Property Owner's Mailing Address Property Location <br /> 25513 12TH STREET W <br /> City,State Zip Code Phone Number Govt.Lot 3 <br /> ZIMMERMAN MN 55398 715-245-8990 /4, 1/., Section 36 <br /> II.Type of Building(check all that apply) Lot# (circle pe) <br /> yppp y) T 40 N; R 16 Eq& <br /> X 1 or 2 Family Dwelling-Number of Bedrooms l 1 Subdivision Name <br /> Block# <br /> ❑Public/Commercial-Describe Use <br /> ❑City of <br /> ❑State Owned-Describe Use CSM Number ❑ Village of <br /> 2234 X Town of <br /> Oakland <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. X New System Replacement 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 apply) <br /> Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.of suitable soil <br /> X Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.DispersaUTreatment Area Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpdst) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> VI.Tank Info Capacity in Total #of Manufacturer <br /> Gallons Gallons Units . o <br /> New Tanks Existing Tanks w e „ c a c <br /> o .. y <br /> a v v� v) w C7 a <br /> Septic or Holding Tank X 2000 1 Weiser x <br /> Dosing Chamber <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 ,mb• "t• • ure MP/MPRS Number Business Phone Number <br /> 884121 715-520-2434 <br /> Luke Schmitz /----" <br /> Plumber's Address(Street,City,State,Zip ..e <br /> PO Box 160 Shell Lake WI 54871 <br /> VIII.County/Department Use Only / <br /> 21 <br /> Approved ❑Disapproved Permit Fee_ Date Issued I i Ag t Sign./ <br /> ❑Owner Given Reason for Denial $.375 1\11(201 •/ 4,'/ <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> i. 375 0 d r, <br /> 000SCowE <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 r x inchtglyze 8 202 <br /> 1 <br /> Burnett County <br /> SBD-6398(R.04/19) I Lend Services Department <br />