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Industry Services Division County <br /> 4822 Madison Yards Way BURNETT <br /> 5 Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> P.O.Box 7162 1043 t 5_r <br /> Madison,WI 53707-7162 <br /> Sanitary Permit Application State Transacti°�n 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 7738 GLEN D E N I N G 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 /> NICK & AMY VOSTERS 07-032-2-41-16-32-4 04-000-019000 <br /> Property Owner's Mailing Address Property Location <br /> 4163 EDGEWOOD ROAD NE Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> CIRCLE PINES, MN 55014 651 - 319 - 3805 SE /,SE ' section 32 <br /> II.Type of Building(check all that apply) Lot# T 41 N R 16 E or w <br /> El or 2 Family Dwelling—Number of Bedrooms 2 NA Subdivision Name <br /> Bock# NA <br /> ❑Public/Commercial—Describe Use NA <br /> ❑City of <br /> ❑State Owned—Describe Use CSM Number Village of <br /> NA ❑✓ Town 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. Elm System Replacement System ['other Modification to Existing System(explain) ['Additional Pretreatment Unit(explain) <br /> B. Of-folding Tank ElIn-Ground lJ'&t-Grade EMound u Individual Site Design Other Type(explain) <br /> (conventional) <br /> C. ElRenewal 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 Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(st) 3ispersal Area Proposed(sf) System Elevation <br /> 300 0.7 428.58 Oa 450 95.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o '$ <br /> New Tanks Existing Tanks o y 1 11 <br /> a U v) H v ii L7 0. <br /> Septic or Holding Tank 750 750 1 WIESER 1 ✓ 11 I <br /> Dosing Chamber I I ❑ ❑ <br /> V.Responsibility Statement- I,the undersigned,assume ri o ibility for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plut .is Sr n e 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., WEBSTER, WI 54893 <br /> VI.County/Department Use Only <br /> pproved ❑Disapproved Permit Fee Date�Issued Issuing Ag t Signal <br /> IDQ?Owner Given Reason for Denial 5 via/aa <br /> Conditions of Approval/Reasons fo Disa proval <br /> alee4-- c, 9 5 ----- <br /> d � <br /> #`fs°° APR 2 8 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less tha 8 1/2 x • ' ' <br /> Burne County <br /> Land Services Department <br /> SBD-6398(R.03/21) <br />