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�%k"';`%�y Department of Safety County <br /> 1 "'< BURNETT <br /> i t, = & Professional Services, <br /> ' Sanitary Permit Number(to be filled in by Co.) <br /> 1, !'i t;; Industry Services Division SPJ_22.-23 l <br /> 47 <br /> `.Ylt�pl\AS',/ <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. 3060 ASPEN TERRACE <br /> I.Application Information-Please Print All Information i i9y10 <br /> Property Owner's Name Parcel# <br /> DEAN B. HILGERS 07-028-2-40-14-07-5 15-706-088000 <br /> Property Owner's Mailing Address Property Location <br /> 6980 LAKETOWN PKWY Govt.Lot NA <br /> City,State Zip Code Phone Number <br /> WACONIA, MN 55387 /. __ _v., section 07 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 14 <br /> EX or 2 Family Dwelling-Number of Bedrooms 2 84 Subdivision Name <br /> Bock# SPRING GREEN ADDN. <br /> ❑Public/Commercial-Describe Use - <br /> NA 0 City of <br /> ❑State Owned-Describe Use CSM Number 0 Village of <br /> NA l#l'own 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. <br /> [3(New System Replacement System L Other Modification to Existing System(explain) ❑Additional Pretreatment Unit(explain) <br /> B. <br /> ❑ Holding Tank [Xn-Ground ❑ At-Grade ❑ Mound Individual Site Design 9ther Type(explain) <br /> (conventional) -WEOMAT <br /> C. ❑ Change of Plumber List Previous Permit Number and Date Issued <br /> ❑ Renewal Before ❑ Revision F' Transfer to New Owner <br /> Expiration <br /> IV.Dispersal/Treatment Area and Tank Information: <br /> Design Flow(gpd) Design Soil Application Ratc(gpd/sf) Dispersal Area Required(st) Dispersal Arca Proposed(sf) System Elevation <br /> 300 2.0 150 162.50 96.75 FT. <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units t o 'c o <br /> '-New Tanks Existing Tanks c 2 y " <br /> V � y y <br /> a U vi y rn iZ C7 a <br /> Septic or Holding Tank 840 --- 840 1 WIESER (COMBO) x <br /> Dosing Chamber 500 5 <br /> V.Responsibility Statement- I,the undersigned,a e res o i rlity for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) PI nb '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) <br /> 24884 S.T.H. 35, SIREN, WI 54872 <br /> VI.County/Department Use Only <br /> pproved 0 Disapproved Permit Fc Date Issued Is gent ignatur <br /> de- <br /> ❑Owner Given Reason for Denial $ <br /> 4 '' 507/aa , <br /> Conditions of Approval/Reasons for Disapp oval <br /> /T,,0f v i c;it in,:i air,fe Se P;f'v <br /> 4 <br /> ale(A- 4.11 %fri.b IECEOVE --- <br /> , <br /> / s FP 2 R 2fl22 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 l/2 s II.chelep size <br /> Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />