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"-% , Department of Safety County <br /> ETT <br /> D S `� & Professional Services, Sanitary Permit Number(to(t be filled in by Co.) <br /> PS , Industry Services Division SAN.22_2� <br /> C1T_22 _lam, �leff�yy <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 <br /> purposes in accordance with the Privacy Law,s.15.04(1)(m),Stats. (SAME) <br /> I.Application Information—Please Print All Information_ <br /> Property Owner's Name Parcel# <br /> JANE E. ETH1( <br /> ERTON JENSEN 07-014-2-38-15-04-5 15-685-017000 <br /> Property Owner's Mailing Address Property Location <br /> 24750 SAND LAKE SHORES TRAIL Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> WEBSTER, WI 54893 612 -272 -0378 /, '/., Section 04 <br /> II.Type of Building(check all that apply) Lot# T 38 N R 15 iscfw <br /> 0.0 or 2 Family Dwelling—Number of Bedrooms 4 7 Subdivision Name <br /> 13Iock# SAND LAKE SHORES <br /> ❑Public/Commercial—Describe Use <br /> NA ❑City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> NA Mown of LAFOLLETTE <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 /> U New System ZReplacement System ❑ Other Modification to Existing System(explain) ❑ Additional Pretreatment Unit(explain) <br /> B' ❑HoldingTank �In-Ground ❑ At-Grade <br /> ❑ Mound ❑ Individual Site Design El Other Type(explain) <br /> (conventional) <br /> C. ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner List Previous Permit Number and Date Issued <br /> Expiration 580815 <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(st) System Elevation <br /> 600 0.7 857.15 900 98.00 FT. <br /> Capacity in ' Total #of Manufacturer <br /> Tank Information Gallons Gallons Units 2 o v <br /> New Tanks Existing Tanks `I'' c 2 aj - K A <br /> U I! in z rn iL C: n-. <br /> Septic or Holding Tank 2500 2500 1 WIESER X <br /> Dosing Chamber 750 _ 1 WIESER X <br /> V.Responsibility Statement- I,the undersigned, sume re/710 <br /> for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Pl er's Si n MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) <br /> 24884 S.T.H. 35, SIREN, WI 54872 <br /> VI.County/Department Use Only <br /> Approved ❑Disapproved Permit Fee Q� Date Issued/ I n Age Signature <br /> ❑Owner Given Reason for Denial $'j 2-5 12l1(J/ ?.? �• <br /> Conditions of Approval/Reasons for Di pproval <br /> 01oji eta( ,D N R • 43 �/ weJ-�a s lECEOVE --)-) <br /> Ic;ca 2 U 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 1 inches n size <br /> 03/22) Burnett County <br /> SBD-6398 <br /> (R. Land Services Department <br />