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R {tT, County <br /> ` �^ Ins Burnett <br /> �J, M 1 �4 Nices Division <br /> T,Washington Ave Sanitary Permit Number(to be filled in by Co.) <br /> IRE® P.O. Box 7162 <br /> �c Madison,WI 53707-7162 K' -��' a. V <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. 30050 SHAW DR <br /> I. Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> STEPHEN E&DAWN E NELSON 07-032-2-41-15-27-5 15-476-045000 <br /> Property Owner's Mailing Address Property Location <br /> 5168 PAR LANE NW <br /> Govt.Lot <br /> City,State Zip Code Phone Number '/., '/., Section 27 <br /> ROCHESTER,MN 55901 (circle one) <br /> T41N15; RWEorW <br /> II.Type of Building(check all that apply) Lot# <br /> ® 1 or 2 Family Dwelling-Number of Bedrooms # 35 Subdivision Name <br /> MINNEWAUKON ASSESSOR PLAT <br /> ❑Public/Commercial-Describe Use Block# <br /> 0 City of <br /> ❑State Owned-Describe Use <br /> CSM Number 0 Village of <br /> ® Town of Swiss <br /> III.Type of Permit: (Check only one box on line A. Complete line B if applicable) <br /> A. 0 New System ® Replacement System 0 Treatment/Holding Tank Replacement Only 0 Other Modification to Existing System(explain) <br /> B. 0 Permit Renewal 0 Permit Revision 0 Change of 0 Permit Transfer to New List Previous Pemtit 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 0 At-Grade 0 Mound>24 in.of suitable soil ® Mound<24 in.of suitable soil <br /> ❑ Holding Tank 0 Other Dispersal Component(explain) 0 Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Application Dispersal Area Required(sf) Dispersal Area Proposed(si) System Elevation <br /> 600 Rate(gpdsf) 857.14 904 87.5-81.5 <br /> .7 <br /> VI.Tank Info Capacity in <br /> Gallons Total #of Gallons Units Manufacturer .) <br /> New Tanks Existing Tanks a. U is.0 a <br /> Septic or Holding Tank x 1250 1 Wieser ® 0 0 0 0 <br /> Dosing Chamber 0 7:1- <br /> 0 0 0 <br /> VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) 'lumb- '-ignature401.1.. __ MP/MPRS Number Business Phone Number <br /> Luke Schmitz 884121 715-468-2434 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> PO Box 160 Shell Lake WI 54871 <br /> VIII.County/Department Use Only <br /> Approved 0 Disapproved Permit Feed Gd Date Issued Issuing Agent Signature / <br /> ❑Owner Given Reason for Denial $ 37�+ ' 1f�44s--' �ie `.i, 411 //4411 <br /> IX.Conditions of ApprovaUReasons for Disapproval <br /> E EE IN E M <br /> County �_i i i <br /> 2018 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 v2;z I I in4hes �� 0 <br /> SBD-6398(R03/14) BURNETT COUNTY <br /> ZONING <br />