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Department of Safety County <br /> BURNETT <br /> US & Professional Services, <br /> P Sanitary Permit Number o be filled in by Co.) <br /> S Industry Services Division <br /> ---- - - State Transaction Nu e 4d`�8 633 <br /> Sanitary Permit Application <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. <br /> I.Application Information—Please Print All Information — <br /> (SAME) <br /> Property Owner's Name Parcel# <br /> WILLIAM&ALICE RUDIE FAMILY TRUST 07-028-2-40-14-29-5 05-001-011001 <br /> Property Owner's Mailing Address Property Location <br /> 2977 OAK LAKE ROAD <br /> Govt.Lot I <br /> City,State Zip Code Phone Number <br /> WEBSTER,WI 54893 218-721-8404 /+, '/a, Section 29 <br /> II.Type of Building(check all that apply) Lot# T 40 N R 14 w <br /> IZN or 2 Family Dwelling—Number of Bedrooms 3 NA Subdivision Name <br /> Block# NA <br /> Cl Public/Commercial—Describe Use <br /> NA 0 City of <br /> ❑State Owned—Describe Use CSM Number 0 Village of <br /> IXI'own of--SCOTT <br /> NA <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 /> ❑New System ri Replacement System L Other Modification to Existing System(explain) L Additional Pretreatment Unit(explain) <br /> B' ❑ Holding Tank Li(In-Ground ❑ At-Grade ❑ Mound ❑ Individual Site Design <br /> g DCOther Type(explain) <br /> (conventional) GEOMAT <br /> C. ❑ Renewal Before ❑ Revision ❑ Chan a of Plumber 1st Previous Permit Number and Date Issued <br /> g ❑Transfer to New Owner <br /> Expiration NK <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(sf) System Elevation <br /> 450 2.0 225 227.50 97.00 <br /> Capacity in Total #of Manufacturer <br /> Tank Information Gallons Gallons Units v o u <br /> New Tanks Existing Tanks 0. c u b y <br /> m <br /> kU in y rn 2a 0. <br /> Septic or Holding Tank 1000 1000 1 WIESER(COMBO) X <br /> Dosing Chamber 650 <br /> 50 <br /> V.Responsibility Statement- I,the undersigned,assu respons' i for installation of the POWTS shown on the attached plans. <br /> Plumber's Name(Print) Plumb ' Signatu MP/MPRS Number Business Phone Number <br /> CORY J. JACKSON ,�� 8224339 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 a2 Date Issued I / ggA�gentt ignature <br /> 1,I7 _ __, <br /> S 1-1>�j ar zo ii 1/ v2/ L I �_IL �sill/�• <br /> El Owner Given Reason for Denial <br /> Conditions of Approval/Reasons for Disapprov I <br /> (its <br /> 1. 1 I o1)5rd'e we45 cfo" 1013(4 w�}-A cl6fAc+- © M C r_l <br /> �rat ()lark( eGq,I:* L e ?�-�2'C 140- " <br /> •if rill 50:Is. <br /> SEP 2 0 20 2022 <br /> Attach to complete plans for the system and submit to the County only on paper not less than 8 in a 11 in1hes in size <br /> II Burnett County <br /> SBD-6398(R.03/22) Land Services Department <br />