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Industry Services Division County <br /> 4822 Madison Yards Way BURNETT <br /> v.�$ Madison,WI 53705 Sanitary Permit Number(to be filled in by Co.) <br /> : P.O.Box 7162 'BAN — --.C.'7 64311156 <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 PWTS-052200747-C <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 [ L� <br /> purposes in accordance with the Privacy Law,s. 15.04(1Xm),Stats. ? 3 C.T.H. A 3�02 U-/ <br /> I.Application Information-Please Print All Information ( eti f 'ae VD 1430f39 <br /> Property Owner's Name Parcel# <br /> DOLLAR GENERAL CIO KARI BUDGE 07-028-2-40-14-16-3 04-000-9455360' <br /> Property Owner's Mailing Address Property Location 0161 W <br /> 27001 WILLIE ROAD Govt.Lot <br /> NA <br /> City,State Zip Code Phone Number <br /> WEBSTER, WI 54893 SE 1/4,SW /, section 16 <br /> H.Type of Building(check all that apply) Lot# T 40 N R 14 E or/W <br /> Di 2 Family Owelling-Number of Bedrooms (PENDING) Subdivision Name (, <br /> ElPublic/Commercial-Describe Use <br /> RETAIL STORE Block# NA <br /> NA City of <br /> State Owned-Describe Use CSM Number ❑Village of <br /> (PENDING) 2Town of SCOTT <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. ONew System replacement System []Other Modification to Existing System(explain) DAdditional Pretreatment Unit(explain) <br /> B. []Holdin Tank �In-Ground DAt-GradeDesignType(explain) <br /> g � Mound Individual Site Other <br /> (conventional) <br /> C. ❑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 Information: <br /> Design Flow(gpd) Design Soil Application Rate(gpd/sf) Dispersal Area Required(st) Dispersal Area Proposed Of) System Elevation <br /> 450 2.0 225 227.50 99.00 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units o o ,a, o <br /> New Tanks Existing Tanks w y -y iu m14 <br /> n U (n m cn w c7 a. <br /> - <br /> Septic or Holding Tank 1000 1000 1 WIESER (COMBO) I / I I- I I I <br /> Dosing Chamber 650 65 <br /> I InoO <br /> V.Responsibility Statement-I,the undersigned,ass ®e sibil for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plu 's Si a MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON / 824339 715-866-8944 <br /> Plumber's Address(Street,City,State,Zip Code) V <br /> 9306 BLACK BROOK RD., WEBS R, WI 54893 <br /> VI.County/Department Use Only <br /> (Approved 0 Disapproved Permit Fee OQ Date Issued Issuing Age Signature <br /> ❑Owner Given Reason for Denial 1125 5//25'? ����� <br /> Conditions of Approval/Reasons or Di proval <br /> t) <br /> R E © <br /> f] V Eill <br /> MAY 1 1 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than a 1/2 in -in size <br /> — Burnett County <br /> SBD-6398(R.03/21) Land Services Department <br />