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�,o�""rME'NT Industry Services Division County <br /> 4822 Madison Yards Way BURNETT <br /> '` K Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> $) P.O.Box7162 ,^,,,11 /L <br /> `\\ Madison,WI 53707-7162 S F )-�a✓!�� G4 6 g39 <br /> \'"F. phi", ' l'5!-2.2- l I.'.- <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 are 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 5161 LAKE 26 ROAD <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 /> DEAN & AMY MITCHELL 21689 <br /> Property Owner's Mailing Address Property Location <br /> 10865 367TH STREET Govt.Lot -- <br /> City,State Zip Code Phone Number <br /> NORTH BRANCH, MN 55056 651 - 983 - 2389 NW 'A, NW /, Section 28 <br /> II.Type of Building(check all that apply) Lot# T 41 N R 15 E or� <br /> Ell or 2 Family Dwelling-Number of Bedrooms 2 1 Subdivision Name vVVvvv <br /> Block# NA <br /> Public/Commercial-Describe Use <br /> NA laity of <br /> ❑State Owned-Describe Use CSM Number Village of <br /> #363; V2, P75 Drown of SWISS <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. ✓ ew System a lacement System they Modification to ExistingSystem(explain) Additional Pretreatment Unit(explain) <br /> ❑�' Y � p Y ❑O Y ( P ) ❑ ( P ) <br /> B. DI-folding Tank ElIn-Ground ElAt-Grade ❑Mound El Individual Site Design FOther Type(explain) <br /> (conventional) <br /> C. El Renewal Before ❑Revision ❑Change of Plumber Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Informatian,�''' „ „ t n r <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation <br /> 300 0.7 428.86 450 95.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units 2 o 'fl <br /> New Tanks Existing Tanks te o 22 t t <br /> Vy yp <br /> a U FA . rn is. C7 w <br /> • <br /> Septic or Holding Tank 750 750 1 WIESER I I I I I II I <br /> Dosing Chamber = ETI ❑ ❑ <br /> V.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) P1,1 mb is Signature MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON / 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 9306 BLACK BROOK RD., A STER, WI 54893 <br /> VI.County/Department Use Only <br /> 14 Permit Fee Date Issued, Is n Ag t Signa <br /> Approved ❑Disapproved $ �� 7/ (/�� <br /> ❑Owner Given Reason for Denial 2". <br /> C'Conditions of Approv l/Reasons�fppr Disa proval r k,tt.3q5 a 'ifk <br /> 50`- <br /> 0l ec 4- a 5�J't�c.c `, C-K.) 47-19 S 73" <br /> 1 , <br /> ECE [IVIET")) <br /> JUL S 2022 J <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 la r in s in size <br /> Burnett County <br /> SBD-6398(R.03/21) Land Services Department <br />