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-:' " Industry Services Division County <br /> 4822 Madison Yards Way BURNETT <br /> oS Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> P$ P.O.Box 7162 90/Q..22- 9,2. <br /> Madison,WI 5 3 707-7 1 62 C-1_O--a _6, 14348- <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 NA <br /> is required prior to obtaining a sanitary permit.Note:Application forms for state-owned POWTS arc submitted to Project Address(if different than mailing address) <br /> the Department of Safety and Professional Services.Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. � � <br /> I.Application Information-Please Print All Information <br /> Property Owner's Name Parcel# <br /> J E F F R EY R. & S H E I LA M. S PAN I E R 07-042-2-38-18-17-5 15-856-020000 <br /> Property Owner's Mailing Address Property Location 4 .5r7q <br /> 1160 DELLWOOD STREET S., APT. 104 Govt.Lot NA ! F <br /> City,State Zip Code Phone Number <br /> CAMBRIDGE, MN 55008 612 - 839 - 6744 %, 'A, Section 17 <br /> II.Type of Building(check all that apply) ' Lot# T 38 N R 18 E oV <br /> Ell or 2 Family Dwelling-Number of Bedrooms 2 4 Subdivision Name <br /> Block# WOOD RIVER <br /> ❑Public/Commercial-Describe Use . <br /> 2 City of <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> NA ❑✓ 7bwn of WOOD RIVER <br /> III.Type of POWTS Permit:(Check either"New"or"Replacement"and other applicable on line A. Check one box on line B.Complete line C if <br /> applicable.) <br /> A. <br /> ❑✓ New System Replacement System ❑Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B. ❑Holding Tank 11 In-Ground ❑At-Grade ❑Mound t❑Individual Site Design jOther Type(explain) <br /> (conventional) <br /> C. ID RenewalBefore El Revision ❑Change of Plumber Dransfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sl) System Elevation <br /> 300 0.5 600 612 97.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units U U ti - <br /> New Tanks Existing Tanks En CA <br /> o L m CA <br /> a U in ,,, yr 47, C7 A. <br /> Septic or Holding Tank 750 750 1 WIESER V <br /> Dosing Chamber I I ❑ = ❑ <br /> V.Responsibility Statement-I,the undersigned,assumes onsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu er's i azure MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON4 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 BLACK BROOK RD., WEBS ER, WI 54893 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Date Issued Z Iss gge t Signatu <br /> ❑Owner Given Reason for Denial Su� C//77�?- 4t <br /> Conditions of Approval/Reasons f rsappro al �'�J <br /> NleeA- a.dl s� CK1/ G7 $ila7 <br /> IECEOVE <br /> MAY 1 7 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches di STL♦ <br /> Burnett County <br /> Land Servlcia Department <br /> SBD-6398(R.03/21) <br />