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0o*e"��i,,w > Industry Services Division County <br /> p': 4822 Madison Yards Way BURNETT <br /> k 4' K) Madison,WI 53705 Sanitary Permit Number(to be filled in byCo.) <br /> , P.O.Box 7162 Jam► - _O9 6L13UO2. <br /> \ Madison,WI 53707 7162 <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 (SAME) Ak\36 5 <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 /> PATRICK L. & SUSAN L. McFADDEN 07-020-2-40-16-23-5 05-007-023000 <br /> Property Owner's Mailing Address Property Location <br /> 6289 SCHOONOVER ROAD Govt.Lot 7 <br /> City,State Zip Code Phone Number <br /> WEBSTER, WI 54893 608-385-9699 '%' 14, Section 23 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 16 I:or W <br /> Ell or 2 Family Dwelling—Number ofBedrooms 2 15 D-760 Subdivision Name <br /> Block# <br /> OPublic/Commercial—Describe Use <br /> NA City of <br /> ❑State Owned—Describe Use CSM Number 'Pillage of <br /> NA Drown of OAKLAND <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. ❑New System Replacement System ❑Other Modification to Existing System(explain) Additional Pretreatment Unit(explain) <br /> B. L_ <br /> Holding Tank ❑In-Ground ElAt-Grade EMound ❑Individual Site Design Other Type(explain) <br /> (conventional) II—' <br /> C. [IRenewal Before ❑Revision ❑Change of Plumber ['Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration N K <br /> IV.Dispersal/Treatment Area and Tank Information: � <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required l50 Dispersal Area Proposed(sf) System Elevation <br /> 300 NA NA NA NA <br /> Capacity in Total #of Manufacturer <br /> y <br /> Tank Information Gallons Gallons Units a : U :1 y N <br /> New Tanks Existing Tanks 1.-. a y ii v, <br /> .. U in to iL. C7 CL <br /> Septic or Holding Tank 1060 1060 1 INFILTRATOR <br /> I <br /> Dosing Chamber 1530 1530 1 INFILTRATOR I I = Q I O I V <br /> V.Responsibility Statement- I,the undersigned,assume resp si ility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plum..,'s Sign r MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON • 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> r, <br /> 9306 BLACK BROOK RD., WEBST R, WI 54893 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Q� Date Issued Issuing Agent ignatur <br /> ❑Owner Given Reason for Denial S 375 2 1 J,!)-9. <br /> Conditions of Approval/Reasons for Disapproval <br /> ►- Meek q(1 sekbctc _ <br /> tif <br /> 1 <br /> FED 9 2022 <br /> Burnett County <br /> Attach to complete plans for the system and submit to the County only on paper not less flan 8 ili.1ant3irloe& epartment <br /> o <br /> SBD-6398(R.03/21) <br /> elf.-4X (4b 13�5n <br />